Complete Care At Harborage LLC

Based on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 2 of 32 residents (Resident #122 and Resident #221) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 4/27/26 at 8:42 AM, the surveyor observed Resident #122 lying in bed, the resident's call device was wrapped around itself and dangled over the outlet on the wall, and out of reach of the resident. On 4/28/26 at 11:27 AM, the surveyor made a second observation of Resident #122 lying in bed. The call device was in the same position as the previous observation, out of reach of the resident. On 4/28/26 at 12:35 PM, the surveyor interviewed Certified Nursing Assistant #1 (CNA #1) and Certified Nursing Assistant #2 (CNA #2) who both observed and acknowledged the call device was out of reach of the resident. 2. On 4/27/26 at 8:34 AM, the surveyor observed Resident #221 lying in bed, the resident's call device extended…

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 #2669783 and #2735273 Based on interview, record review, and review of facility documents, it was determined that the facility failed to ensure the resident representative was notified of a significant change in condition, including a fall for 1 of 2 residents (Resident #252) and a resident's death for 1 of 1 resident (Resident #250), and failed to ensure such notification was documented in the medical record for 2 of 2 residents (Resident #250 and Resident #252) reviewed for notification of change. This deficient practice was evidenced by the following: 1.On [DATE] at 11:53 AM, Surveyor #1 (S #1) reviewed the closed records of Resident #250. A review of the admission Record (AR) or face sheet (an admission summary), revealed the resident had diagnoses which included, but were not limited to; acute respiratory failure (inability to maintain adequate oxygenation), pleural effusion (fluid buildup around the lungs), anemia, heart failure, and malignant neoplasm of the bladder. A review of the progress…

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.

NJ#2643214Based on observation, interview, and record review, it was determined that the facility failed to maintain residents' environment in a safe, clean, comfortable, and homelike surrounding. This deficient practice was identified for 1 of 32 sampled residents (Resident #221) and 1 of 6 residents (Unsampled Resident) from resident council meeting reviewed.This deficient practice was evidenced by the following: 1. On 4/27/26 at 8:35 AM, Surveyor #1 (S #1) observed Resident #221 lying in bed, the floor mat on the right side of the resident was dirty, stained, and had wet pools on it in multiple places. On 4/27/26 at 10:31 AM, S #1 made a second observation of the floor mat which was still stained and had wet pools on it in multiple places. On 4/28/26 at 12:23 PM, S #1 made a third observation of the floor mat, which was vertical by the window wall, and stained in multiple places with dried colored chunks and pieces. On 4/28/26 at 12:45 PM, S #1 interviewed Certified Nursing Assistant #1 (CNA #1) who stated they saw the floor mat was dirty on 4/27/26 and called housekeeping then.…

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 interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure grievances were documented on the facility grievance form and responses were documented according to facility policy. This deficient practice was identified for 1 of 38 residents (Resident #9) reviewed. This deficient practice was evidenced by the following: On 4/27/26 at 9:16 AM, the surveyor observed Resident #9 who was seated up in bed and stated that they had been in the facility for two years. A review of Resident #9's admission Record (AR) or face sheet (an admission summary) revealed that the resident was admitted to the facility with diagnoses that included but were not limited to heart failure (chronic, progressive condition where the heart muscle cannot pump blood efficiently, often caused by coronary artery disease, high blood pressure, or heart attacks) and hypertension (high blood pressure). A review of Resident #9's most recent comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with 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 interviews and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 2 of 38 residents, (Resident #14 and Resident #229), reviewed for MDS, in accordance with federal guidelines. This deficient practice was evidenced by the following:According to the Resident Assessment (RAI) Manual, dated October 2025, RAI-required Assessment Summary:-The admission (Comprehensive) assessment, the MDS completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The CAA(s) (Care Area Assessment) Completion date no later than 14th calendar day of the resident's admission (admission date + 13 calendar days). The Care Plan Completion date is no later than CAA(s) Completion date + 7 calendar days. The Transmission date is no later than Care Plan Completion date + 14 calendar days.-The Quarterly (non-comprehensive) assessment, the MDS completion date ARD (assessment reference date) + 14…

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 interviews and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for 3 of 38 residents (Residents #10, #14, and #85) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 4/27/26 at 10:00 AM, Surveyor #1 (S #1) observed Resident #10 awake, sitting in the wheelchair (w/c), alert and oriented, able to verbalize needs to staff. On 4/28/26 at 10:07 AM, S #1 reviewed the electronic medical record (eMR) of Resident #10, which revealed the following: A review of the admission Record (AR) or face sheet (an admission summary) reflected that Resident #10 was admitted with diagnoses that included, but were not limited to, other specified depressive (feeling of sadness) episodes. A review of the recent quarterly Minimum Data Set (qMDS), with an assessment reference date (ARD) of 3/17/26, reflected a Brief Interview for Mental Status (BIMS) score of 13 out…

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.

REPEAT DEFICIENCYBased on observations, interviews, and review of medical records and facility documents, it was determined that the facility failed to develop and implement a comprehensive plan of care to meet residents' goals, medical, and psychosocial needs. This deficient practice was identified for 3 of 38 residents (Residents #5, #14, and #85) reviewed for care plan. This deficient practice was evidenced by the following: 1. On 4/28/26 at 11:46 AM, Surveyor #1 (S #1) observed Resident #5 lying in bed awake and able to answer S #1's inquiry. On 4/28/26 at 1:09 PM, S #1 reviewed the electronic medical record (eMR) of Resident #5, which revealed the following: A review of the admission Record (AR) or face sheet (an admission summary) reflected that Resident #5 was admitted with diagnoses that included but were not limited to peripheral vascular disease (PVD, disorder of the circulatory system). A review of the most recent quarterly Minimum Data Set (qMDS) (an assessment tool used to facilitate the management of care), with an assessment reference date (ARD) of 3/20/26, reflected…

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 documents, it was determined that the facility failed to ensure services provided met professional standards of practice by failing to follow the physicians orders for 3 of 38 residents (Residents #9, # 35, and #213) reviewed. This deficient practice 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 stated, The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or 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. Nursing Board The Nurse Practice Act for the State of New Jersey stated, The practice of nursing as 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 #260384Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to; a.) ensure a timely initial nursing assessment was completed, b.) ensure physician ordered medication was administered, and c.) ensure hospice services were documented, communicated, and coordinated in accordance with the resident's plan of care and standards of clinical practice. This deficient practice was identified for 2 of 2 residents (Resident #11 and Resident #249) reviewed for quality of care, 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…

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 documents it was determined that the facility failed to, a.) follow the physician order and ensure assistive device was consistently applied for 1 of 2 residents (Residents #14) and b.) a physician order was obtained with regard to use of an assistive device for 1 of 2 residents (Resident #253), in accordance with facility policy and standard of practice.This deficient practice 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…

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 documents, it was determined that the facility failed to: a.) to ensure fall interventions were consistently implemented for residents identified as being high risk for falls who sustained injuries from fall and b.) ensure a resident with severe cognitive impairment, who was at risk for elopement and had a known history of wandering was appropriately supervised and monitored to ensure safety, prevent elopement, and/or exiting of the building. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #14) and for 1 of 1 resident reviewed for elopement (Resident #209), in accordance with standards of clinical practice and facility's policies and procedure. This deficient practice 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…

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 record review, it was determined that the facility failed to provide appropriate treatment and services for a resident receiving enteral feeding. This deficient practice was identified for 1 of 3 residents (Residents #73), reviewed for enteral (tube) feeding.This deficient practice was evidenced by the following: On 4/29/26 at 9:34 AM, the surveyor reviewed the electronic medical record (eMR) of Resident #73. A review of the admission Record or face sheet (an admission summary) documented the resident had diagnoses that included but were not limited to, Alzheimer's disease and unspecified severe protein-calorie malnutrition. A review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, with an assessment reference date (ARD) of 3/3/26, reflected that resident was rarely/never understood. In Section K (Swallowing/Nutritional Status), Resident #73 was coded as receiving nutrition through a feeding tube while a resident. A review of the physician's order (PO) dated 4/21/26, included, three times 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.

Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that residents received the necessary respiratory care and services, according to the standard of clinical practice, specifically that respiratory equipment were labeled and stored in accordance with infection control measures and cautionary signage for oxygen services for 2 of 7 residents reviewed for respiratory care (Resident #227 and #234).This deficient practice 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…

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 documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for 1 of 5 days. This failure could affect the knowledge of the availability of staff to care for the residents, resident representative, and visitors.This deficient practice was evidenced by the following: On 4/27/26 at 6:18 AM, upon entry into the facility, the surveyor observed a posted Nursing Home Staffing Report (NHSR) in the reception area of the lobby, dated 4/25/26 Day Shift, 7:00 AM-3:00 PM (7-3 shift), Evening Shift 3:00 PM-11:00 PM (3-11 shift), and Night Shift 11:00 PM-7:00 AM (11-7 shift). The NHSR reflected current census (total number of residents) of 230 for all shifts. On 4/30/26 at 8:00 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) for copies of midnight census for dates of 4/25/26 and 4/26/26, list of admissions on 4/25/26 and 4/26/26, and the census for every shift on 4/25/26 and 4/26/26. On 4/30/26 at 9:00 AM, the surveyor interviewed the Staffing…

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 record review, it was determined that the facility failed to ensure the Consultant Pharmacist (CP) identified an irregularity during the drug regimen review (DRR) of a resident with chronic kidney disease. The deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #7) and was evidenced by the following:Reference:According to the manufacturer's boxed warnings (the highest safety- related warnings that medication can have, assigned by the Food and Drug Administration.) for Epogen (epoetin alfa): In controlled trials, patients with chronic kidney disease (CKD) experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered erythropoiesis-stimulating agents (ESAs) to target a hemoglobin level of greater than 11grams /deciliter (g/dl). On 4/27/26 at 6:59 AM, the surveyor observed Resident #7 in a low positioned bed, was receiving oxygen (O2) via nasal cannula (a tube with 2 prongs at the end that deliver O2 through the nose), the O2 concentrator was on and set…

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 facility documentation, it was determined that the facility failed to dispose of garbage and refuse properly in a manner to maintain a sanitary environment and prevent potential pests.This deficient practice was evidenced by the following: On 4/27/26 at 10:02 AM, a tour of the refuse area revealed, one covered compactor with six used gloves around the perimeter, a used mask, debris, and garbage on the front of the compactor on the ground. The surveyor asked who was responsible for keeping the area clean and the Director of Plant Operations (DPO) stated that the hospital housekeeping staff were responsible for cleaning the area, once a week. The DPO confirmed the refuse area should not have garbage and gloves around the perimeter. On 4/28/26 at 11:25 AM, on second day of tour, the surveyor observed the refuse area still with garbage in front and used gloves and mask. The DPO stated the company picks up the compactor every Friday and that the hospital uses it too. The surveyor requested from the FSD policies for the refuse area.On 4/28/26…

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 pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene practices for 5 of 11 staff (3 Certified Nursing Aides and 2 Kitchen Leadership Staff), during incontinence tour and kitchen tour, and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy.This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24 revealed.Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient .Before moving from work on a soiled body site to a clean body site on the same patient .After touching a patient or the patient's immediate environment. After contact with blood, body fluids, or contaminated surfaces.…

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 and interview, the facility failed to ensure medication rooms on three (2nd nursing unit (NU), 3rd NU, and 5th NU) of four nursing units, did not have expired medical products or items left open. This has the potential to increase of risk of infections due to expiration. Findings include: During observations conducted with Licensed Practical Nurse (LPN)9, revealed the following expired items located in the resident care supplies: 1. Observation on [DATE] at 9:26 AM on the second-floor nursing unit, revealed the following expired items: (10) Central Line Trays w/chloral prep expired on [DATE]. (2) Huber needles (1) expired on [DATE], and (1) expired on [DATE]. (1) Microbore Extension set expired on [DATE]. (1) IV Securement Kit expired on [DATE]. (1) 30ml sterile water syringe left open. (1) IV (intravenous) administration kit that expired on [DATE]. (12) Replacement caps expired on [DATE]; (29) on [DATE], and (24) on [DATE]. 2. Observation conducted on [DATE] at 10:17 AM on the third-floor…

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 record review, interview, and policy review, the facility failed to develop care plans related to use and monitoring of psychoactive medications for one (Resident (R) 49 of five residents reviewed for unnecessary medications out of a sample of 35 residents. Findings include: Review of R49's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R49 was admitted to the facility on [DATE] with diagnoses that included depression and anxiety, Review of R49's physician orders, located under the Physician Orders tab of the EMR, revealed medication orders for Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 milligram (mg) three times a day for agitation; Mirtazapine Oral Tablet 7.5 mg at bedtime for depression; and Buspirone HCl Oral Tablet 5 mg three times a day for anxiety. Review of R49's care plan located under the Care Plan tab of the EMR, did not include the use of psychoactive medication or interventions for monitoring for side effects or behaviors.…

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, record review, and policy review, the facility failed to provide two residents (Resident (R) 139 and R108) out of nine residents reviewed for Activities of Daily Living (ADLs) the necessary repositioning and incontinence care to ensure residents dependent on assistance with ADLs received care and services for toileting hygiene and skin protection out of a total sample of 41 residents. Findings include: 1. Review of R139's Face Sheet found in the Resident Report tab of the electronic medical record (EMR) revealed admission on [DATE] with diagnoses including sepsis, extended spectrum beta lactamase resistance, muscle weakness, and benign prostatic hyperplasia. Review of R139's quarterly Minimum Data Set (MDS) located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 08/21/24, revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated moderate cognitive impairment. According to the MDS R139 was always incontinent of urine 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, record review, and facility policy review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility and failed to ensure a medication was administered on dialysis days for one of one residents (Resident (R) 61) reviewed for dialysis out of a sample of 41. Findings include: 1. Review of R61's Face Sheet, found in the Resident Report tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnosis including end stage renal disease, kidney transplant failure, congestive heart failure, hypertension, and diabetes mellitus type two. Review of R61's quarterly Minimum Data Set (MDS) located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 09/10/24 revealed a Brief Interview for Mental Status (BIMS) score of fourteen out of 15, which indicated no cognitive impairment. R61 was documented to receive dialysis while a resident. Review of R61's EMR under the Resident Orders tab under the Resident…

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 policy review, the facility failed to ensure that one of 10 medication carts (fifth floor south) and one of one rolling cart (fifth floor) were not left unsecured and unmonitored when medication cart was unlocked. This the potential for medication diversion and for residents to obtain medications that could affect their health. Findings include: Review of the facility's policy titled Medication Storage dated 07/01/24, revealed, it is the policy of this facility to ensure all medications housed on our premises will be stored in the medication rooms/medication carts according to the manufacturer recommendations .All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls .During a medication pass, medications must be under the observation of the person administering medications or locked in the medication storage area/cart. During observations conducted on the fifth-floor nursing unit on 12/03/24 at 12:07PM, the 5 South medication…

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 interviews, record review and policy review, the facility failed to maintain an accurate medical record for two (Resident (R) 71 and R22) of six residents reviewed for nursing services. The facility failed to ensure medications administrations were accurately documented administration record. Findings include: 1. During an interview with R71's Resident Representative (RR) on 12/03/24 at 12:20 PM, she stated that R71 has missed medication administrations. Review of R71's Electronic Medical Record (EMR), under the Orders tab revealed Medication Administration Record (MAR) dated November 2024 lacked documentation that the following medications were not administered on 11/14/24 and 11/26/24 for the following medications: Lasix (diuretic) 20 milligram (mg), Sertraline (antidepressant) 100mg, Divalproex (antipsychotic) 125mg, Memantine (miscellaneous central nervous system agent) 10mg (twice daily), and Donepezil (Acetylcholinesterase inhibitor) 10mg. Further review of the Nurse notes in the EMR, under…

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 interviews and record review, as well as review of pertinent facility documents on 1/3/24, 1/5/24, and 1/8/24 it was determined that the facility failed to administer medication as ordered and to follow the facility's policy titled Administering Medication for 1 of 8 residents (Resident #6), reviewed for medication administration. This deficient practice was evidenced by the following: According to the admission RECORD, Resident #6 was admitted to the facility with diagnoses that included but were not limited to: Cerebral Infarction, Hypertension, and Peripheral Vascular Disease. According to the resident's Minimum Data Set (MDS), an assessment tool dated 12/18/23, Resident #6 had a Brief Interview for Mental Status (BIMS) score of 12/15, indicating that the resident cognitive was moderately impaired. A review of the form Order Summary Report (OSR), dated 12/2023 revealed an order initiated on 12/28/23 for Zithromax Oral Tablet 500 milligrams (mg), give 1 tablet by mouth every 12 hours for Upper Respiratory Infection (URI) to be given until 12/31/23. A review of Resident…

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 provide a homelike environment during meal service as evidenced by the following. The deficient practice was observed on 2 out of 3 facility floors during lunch service observation. This deficient practice was evidenced by the following: 1. On 4/10/23 at 1:00 PM, during the lunch meal service located on the 2nd Floor dining room (DR), the surveyor observed that all meals in the DR were served and remained on meals trays. The surveyor also observed the Certified Nursing Assistants (CNA's) who were providing assistance with set-up to the residents in the DR left the lid from the food plate on the table and placed all the empty milk and juice containers along with straw papers and other trash in front of the resident. The garbage along with the meal tray was left on the table in front of the resident through the entirety of the meal, while residents were eating. On 4/11/23 at 12:55 PM, during the lunch meal service on the 2nd Floor DR, the surveyor observed that all meals in the DR were once again served…

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 record review, it was determined that the facility failed to develop and implement a person-centered baseline care plan (CP) for a resident within 48 hours of admission. This deficient practice was identified for 1 of 2 residents reviewed, (Resident #381) who had impaired communication related to language barrier. This deficient practice was evidenced as follows: On 4/10/23 at 12:43 PM, during the initial tour, the surveyor observed Resident #381 sitting in a wheelchair in their room. The surveyor greeted the resident who responded in Spanish. On 4/17/23 at 12:20 PM, the surveyor observed Resident #381 sitting in their wheelchair in their room. The surveyor greeted the resident who responded in Spanish. At around the same date and time, the surveyor interviewed the Licensed Practice Nurse (LPN) assigned to the resident. The LPN stated that Resident #381 speaks and understands only Spanish and that a translator and a communication board would be needed. The surveyor brought the LPN to Resident #381's room. The LPN acknowledged that there was 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 Based on observation, interview and record review, it was determined that the facility failed to maintain professional standards of nursing practice for 3 of 31 sampled residents observed, Resident #92, #228 and #114 . This deficient practice 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 licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. 1. On 4/18/23 at 8:45 AM, during the medication administration observation (med pass), the Surveyor observed the 5th Floor Registered Nurse (RN) preparing crushed medications for administration to a gastric tube…

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 # NJ00154588 Based on observations, interviews, review of medical records, and review of other pertinent facility documents, it was determined that the facility failed to ensure that timely incontinence care was provided to 1 of 3 residents dependent on staff for care. This deficient practice was observed during a care tour and involved Resident #100. This deficient practice was evidenced by the following: On 4/19/23 at 11:46 AM, the surveyor conducted a care tour with the 2nd floor Licensed Practical Nurse/Unit Manager (LPN/UM). Resident #100 was checked for incontinent care by the 2nd floor LPN/UM. The surveyor observed Resident #100, who was lying in bed, wearing a disposable incontinent brief which appeared to be saturated with urine. There was an absorbent cloth pad underneath Resident #100 which had a yellowish stain on it. The outer border of the stain was a darker yellowish color. The 2nd floor LPN/UM confirmed that the yellow color stain was from urine. On 4/19/23 at 12:00 PM, the surveyor interviewed the 2nd floor LPN/UM. The 2nd floor LPN/UM indicated 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.

Based on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to follow and maintain fall prevention interventions documented on the resident's care plan (CP) for 1 of 2 residents reviewed for falls, Resident #119. The deficient practice was evidenced by the following: On 4/10/2023 at 12:21 PM, the surveyor observed the resident in bed with eyes closed with the right-side floor mat off the floor and leaning against the bed rail. On 4/11/2023 at 12:22 PM, the surveyor observed the resident in bed with eyes closed with the right-side floor mat off the floor and once again leaning against the bed rail. A review of the admission Record face sheet (an admission summary) indicated that the resident had diagnoses which included but was not limited to acute respiratory disease (a serious lung condition that causes low blood oxygen), unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems.), generalized muscle weakness (weakness or…

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 record review it was determined that the facility failed to: a) maintain respiratory care and services for a resident who was receiving an oxygen treatment according to the standards of practice. The deficient practice was identified for 2 of 4 residents, Resident #382 and #114 reviewed for respiratory care. This deficient practice was evidenced by the following: a) On 4/10/23 at 12:56 PM, during the initial tour, the surveyor observed Resident #382 sitting in their wheelchair with oxygen (O2) in use via nasal cannula (n/c) set at 3 liters per minute (3 L/min) attached to a humidified O2 concentrator (a medical device used for delivering O2). The O2 tubing was dated 4/6/23. On 4/18/23 at 11:58 AM, the surveyor observed Resident #382 not in their room. The surveyor observed a nasal cannula on the floor, dated 4/13/23, not in use, and connected to the O2 concentrator. The surveyor reviewed Resident #382's medical record that revealed the following: The Face Sheet revealed that Resident #382 was admitted to the facility with diagnoses that included…

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 # NJ00154588 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure resident's highest practical wellbeing by failing to: a.) provide incontinence care in a timely manner, b.) maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 02/01/2021: One Certified Nurse Aide (CNA) to every eight residents for the day shift. One direct care staff member to every 10 residents for the evening shift, provided that no fewer than half of all staff…

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 hold a medication used to treat high blood pressure in accordance with physician orders. This deficient practice was identified for 2 of 34 residents reviewed for medication management (Resident #124, Resident #92). The evidence was as follows: 1.) On 4/10/23 at 10:35 AM, the surveyor observed Resident #124 in the room with eyes closed. The resident was non-interviewable. The surveyor reviewed Resident #124's medical record. The resident was admitted to the facility on [DATE] with diagnoses that included but not limited to Hypertension and Anoxic Brain Damage. A review of the electronic Physician Orders for April 2023 reflected a physician order (PO) with a start date of 3/2/23 for a medication, Metoprolol Tartrate. The order specified to give 1 tablet of 25 milligrams (mg) every 12 hours for Hypertension and to hold the medication for a systolic blood pressure (SBP) (top number of a blood pressure reading) less than…

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 maintain a medication rate error below 5%. The surveyor observed 2 nurses administer 26 doses of medication to 3 residents and there were 3 errors which resulted in a medication error rate of 11.50 %. The deficient practice was evidenced by the following: 1. On 4/18/23 at 8:45 AM, during the medication administration observation (med pass), the Surveyor observed the 5TH Floor Registered Nurse (RN) preparing crushed medications for administration to a gastric tube (gtube) resident, Resident #92. The RN opened a packet prepared by the pharmacy, marked for 9:00 AM administration that included 2 medications, Metoprolol Tartrate 25 mg to be administered every 12 hours Hold if Systolic Blood Pressure (SBP) is less than (<) 100 and Famotidine 20 mg twice daily. The Surveyor noted that the RN referred to a paper that contained handwritten room numbers and vitals for numerous residents, including Resident #92. The paper…

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 documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in facility name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification, and regulatory requirements, as required, based on the type of services, or supplies the provider…

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 record review, it was determined that the facility failed to maintain proper infection control practices to mitigate the spread of infection for 3 of 36 Residents observed, Resident #92, #39, and #228. The deficient practice was observed on 2 out of 4 facility floors during medication administration observation. This deficient practice was evidenced by the following: 1. On 4/18/23 at 8:45 AM, the Surveyor observed medication administration (med pass) on the 5th floor, Vent Unit performed by a Registered Nurse (RN). The State Surveyor observed the RN prepare the crushed medication for a gastric tube (gtube), ventilator dependent Resident, Resident #92 without washing her hands. The surveyor requested that the RN check Resident #92's vitals due to the physician parameter order. The RN proceeded to check Resident #92's vitals without sanitizing the stethoscope before or after use on this compromised Resident. The RN put on gloves without sanitizing or washing her hands and retrieved gtube administration supplies (container filled with water and bulb…

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.