Skilled Nursing At Pine Village

Based on observation and interview it was determined that the facility failed to ensure the kitchen and remote food service pantry were maintained in a clean and sanitary manner to prevent the spread of potential infection and food borne illness. The deficient practice was evidenced by the following:On 08/25/2025 at 8:59 AM, the surveyor toured the food service pantry with a Dietary Aide (DA) who stated the meals were brought up to the pantry from the main kitchen, and served via the pantry. The DA confirmed the dish machine located in the pantry was also utilized to wash the lunch and dinner dishes. The surveyor observed the following:The walls and ceilings were soiled with various colored debris and stained throughout.The cutting board, attached to the steam table was visibly stained and grooved. The DA moved the steam table away from the wall and the area behind the steam table was soiled with various crumb type debris.The plastic wrap container was soiled with grease type marks.The metal shelves underneath the counter contained three containers that held lids and containers. 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 interview and record review it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) for 1 of 3 residents reviewed for accident and incidents (Resident #22).This deficient practice was evidenced by the following:Refer to F610 On 8/25/25 at 9:30 AM, the surveyor observed Resident #22 in bed. When the surveyor inquired regarding their care, Resident #22 informed the surveyor that they had an accident with the lift machine and their Representative would be able to elaborate on the incident later. On 8/26/25 at 10:30 AM, the surveyor observed a visitor at Resident #22's bedside, the visitor informed the surveyor that two weeks ago, the resident had reported to them pain to the left shoulder after an incident that occurred during transfer with the Sit to Stand lift (STS) (a device used to transfer patients from one seated surface to another) in the bathroom. The visitor further stated that they had reported the incident to the Unit Manager. The surveyor reviewed the medical record for Resident #22. 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 interview, record review, and review of pertinent documents, it was determined that the facility failed to ensure a thorough and complete investigation was conducted, and documented for an injury of unknown origin to ensure a) when a resident reported they were hurt during a mechanical lift transfer while in the bathroom, experienced pain, and b) was diagnosed with a left clavicle fracture, to determine the root cause and implement interventions to prevent recurrence. This deficient practice occurred for 1 of 3 residents reviewed for accidents and incidents (Resident #22) and was evidenced by the following: On 8/25/25 at 9:30 AM, the surveyor observed Resident #22 in bed. When surveyor inquired regarding the resident's care, Resident # 22 informed the surveyor that they had an accident with the lift machine and their Representative (RR) would be able to elaborate on the incident later. On 8/26/25 at 10:30 AM, the surveyor observed the RR at the bedside, who then informed the surveyor that two weeks ago, Resident # 22 reported pain to their left shoulder and informed them 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.

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: a.) ensure wound care was done in accordance with professional standards of practice, and b) staff were trained and followed infection control measures during wound care to prevent potential infection. This deficient practice was identified for 1 of 2 residents reviewed with pressure ulcers (Resident # 2) and was evidenced by the following: On 8/25/25 at 7:58 AM, the surveyor inquired about Resident#2's wound and the nurse confirmed that Resident #2 was admitted with a stage 3 sacral pressure ulcer. The surveyor informed the LPN that she would observe the wound care on the next day. On 8/26/25 at 11:15 AM, the surveyor observed the following wound care provided by the Licensed Practical Nurse (LPN):-The LPN entered the room to provide wound care to Resident #2 sacral wound. The LPN performed hand hygiene (HH) with soap and water, then returned to the treatment cart to collect the items needed for the wound care.…

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 ensure infection surveillance was implemented during a Covid-19 outbreak to limit the spread of a virus and prevent the spread of potential infections ensuring that a.) staff performed hand hygiene prior to serving meals and b.) residents were provided with opportunities to wash their hands prior to dining. This deficient practice was evidenced by the following: During the initial tour of the facility on 8/24/25 at 8:00 PM, the surveyor observed signage posted at the entrance door for all to wear a mask prior to entering the facility. The receptionist informed the team that the facility was in an outbreak of Covid19.On 8/25/25 at 11:21 AM, the surveyor met with the Infection Preventionist (IP), who confirmed the facility was in a Covid-19 outbreak which started on 7/16/25. The IP confirmed that the outbreak included 11 residents and 9 staff members who tested positive for COVID-19. The IP stated that the outbreak will be completed on 8/28/25 if no other cases were identified.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 observations, interviews, record review, and review of facility documents, the facility failed to provide appropriate catheter care for 1 of 2 residents reviewed for urinary catheter with Urinary (Resident #20). This deficient practice was evidenced as follows: On 8/24/25 at 8:30 PM, the surveyor observed Resident #20 in bed. The residents foley catheter drainage bag was noted to be on the left side of the bed, resting directly on the floor. The foley catheter drainage bag was not in a privacy bag.On 8/24/25 at 9:45 PM, the surveyor observed that the resident's foley catheter drainage bag was in the same position, directly touching the floor and was not in a privacy bag. Same observation verified with another surveyor. A review of Resident #20's admission Record reflected that the resident was admitted with diagnoses which included but were not limited to: depression, chronic kidney disease, and urinary retention with an indwelling (fixed in a person's body for a long period of time) catheter.A review of Resident #20's admission Minimum Data Set (MDS), a tool to facilitate…

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 facility documents, it was determined that the facility failed to develop person-centered comprehensive care plans for 2 of 13 residents (Resident #34 and #38) reviewed. This deficient practice was evidenced by the following: 1. According to the Face Sheet, Resident #34 was admitted to the facility with diagnoses which included, but were not limited to, paraplegia (paralysis), pressure ulcer and colostomy. The admission Minimum Data Set (MDS), an assessment tool, dated 03/05/24, indicated that the resident had severe cognitive impairment and required maximum assistance with activities of daily living. The MDS also indicated that the resident received antidepressants, had an indwelling urinary catheter, and a colostomy (an operation that redirects your colon from its normal route, down toward the anus, to a new opening in your abdominal wall). The surveyor reviewed the resident's electronic medical records (EMR) which revealed the following information: The Physician Order Sheet (POS) dated 02/28/24 reflected a 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, record review and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order for oxygen therapy and develop a care plan for respiratory care. This deficient practice was identified for 1 of 1 resident (Resident #43) reviewed for respiratory care. This deficient practice was evidenced by the following: On 04/22/24 at 07:37 AM, during the initial tour the surveyor observed Resident #43 lying in bed sleeping receiving oxygen (O2) via nasal cannula. On 04/23/24 at 11:01 AM, the surveyor observed Resident #43 lying in bed watching TV. At that time, the surveyor interviewed the resident who stated that she received oxygen three (3) liters/minute (3 L/M) via nasal cannula and that the staff change the tubing but was not sure how often it was changed. The surveyor reviewed the medical record for Resident #43. A review of the admission Record face sheet reflected that the resident was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease with (acute) exacerbation…

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

Based on interview and record review, it was determined that the facility failed to evaluate the performance of all Certified Nursing Assistants (CNAs) on an annual basis. This deficient practice occurred with 2 of the 5 CNAs whose personnel records were reviewed and was evidenced by the following: On 04/24/2024 at 10:48 AM, the surveyor reviewed the employee files of 5 randomly selected CNAs which were provided by the facility. The surveyor identified the following: CNA #1 had a hire date of 02/20/19. According to CNA #1's personnel record, the last documented performance appraisal was 05/27/22. There were no annual performance reviews conducted within the past year. CNA #2 had a hire date of 07/26/21. According to CNA #2's personnel record, the last documented performance appraisal was 12/16/22. There were no annual performance reviews conducted within the past year. During an interview with the surveyor on 04/24/24 at 12:05 PM, the Licensed Nursing Home Administrator (LNHA) stated she had been employed at the facility for the last four months. The LNHA stated that performance…

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 ongoing records of communication between the nursing facility and the dialysis center. This deficient practice was identified for 1 of 1 resident (Resident #25) reviewed for dialysis and was evidenced by the following: On 2/3/22 at 10:22 AM, the surveyor interviewed Resident #25 who stated that he/she received dialysis services every week on Monday, Wednesday, and Friday. The surveyor reviewed the medical record for Resident #25. A review of the resident's Face Sheet (an admission summary) reflected that the resident was admitted to the facility in February of 2021 with diagnoses which included end stage renal disease, type II diabetes mellitus, and dependence on renal dialysis. A review of the resident's most recent significant change Minimum Data Set (MDS), an assessment tool dated 12/3/21, reflected a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated a moderately impaired cognition. A further review of the MDS Section O. Special Treatments,…

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 backup medications were available for use for a newly admitted resident. This deficient practice was identified for 1 of 2 Residents (Resident #36) reviewed for thirty-day new admission and was evidenced by the following: On 2/3/22 at 11:04 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the High side medication cart. Located in the top drawer of the medication cart, was a zip top bag with insulin lispro inside. On the label outside of the bag, was Resident #25's printed name that had been scratched out in pen and Resident #36's name had been handwritten in. There was no name on the insulin lispro pen located inside the bag. On 2/3/22 at 11:28 AM, the surveyor interviewed the LPN who stated that when insulin pens came in from the pharmacy labeled with the resident's name or as facility backup, they were stored in the medication room refrigerator until they were opened. Then when we needed them, we took them out of the refrigerator and dated them.…

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.) properly label and date insulin pens once opened and removed from the refrigerator, b.) remove discontinued medication from active inventory, and c.) ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 form) were completed with sufficient detail to enable accurate reconciliation. This deficient practice was identified on 2 of 2 medication carts observed and for 3 of 3 provided DEA forms. The evidence was as follows: 1. On 2/3/22 at 11:04 AM, the surveyor in the presence of the Licensed Practical Nurse (LPN #1) inspected the High side cart and found six zip top bags each containing one opened and undated insulin pen (medication used to regulate blood sugar). Further inspection of the bags revealed the following: Resident #22's insulin glargine pen and liraglutide pen were labeled with the resident's name but not the date the pen was opened. Resident #36's insulin glargine and insulin lispro pens had no name on…

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 records it was determined that the facility failed to implement infection control protocols in a manner that would decrease the possibility of the spread of infection by a.) performing hand hygiene in accordance with the Center for Disease Control and Prevention and facility policy and b.) maintaining a resident's urinary catheter bag off the floor. This was observed with 1 of 3 residents (Resident# 12) reviewed for indwelling urinary catheter and evidenced by the following: 1. On 2/8/22 at 10:41 AM, the surveyor observed the Certified Nurse Aide (CNA) preparing to provide care for Resident #12. The CNA performed hand hygiene, lathering with soap outside the flow of running water for three seconds prior to rinsing with water. At this time, the surveyor interviewed the CNA regarding the facility's policy for hand hygiene. The CNA responded that you wet your hands with water, then lathered your hands with soap applying friction outside the flow of water for ten seconds, then rinsed your hands off with water. The 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.