Actors Fund Home

In the surveyor’s words

From the most serious findings on record at Actors Fund Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 24, 2025

  Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 7/16/25 at 9:27 AM, the surveyor, in the presence of a Kitchen Supervisor/Cook (KS/C) observed the following during the initial kitchen tour:1. A milk chest which contained beverages including milk, juices and soda, the internal thermometer reading was observed at 49 degrees. The KS/C stated the cook was in refrigerator (ref) stocking items and that was why the temperature (temp) was high. The KS/C acknowledged the ref temp should be below 41 degrees. A temp log on the ref also indicated the ref temp should be 41 degrees or less. […]

• No harm, potential for more than minimal, isolatedF638Jul 24, 2025

  Based on interview and record review, it was determined that the facility failed to complete the Quarterly Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the specified timeframe as required. This deficient practice was identified for 1 of 21 residents (Resident #74), whose MDS assessments were reviewed and was evidenced by the following: The Centers for Medicare and Medicaid (CMS) MDS Version 3.0 Resident Assessment Instrument (RAI) Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. […]

• No harm, potential for more than minimal, isolatedF657Jul 24, 2025

  Based on observation, interview, and record review, it was determined that the facility failed to update and revise the comprehensive care plan of a resident. This deficient practice was identified for 1 of 21 residents reviewed, Resident#34, and as 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… […]

• No harm, potential for more than minimal, isolatedF658Jul 24, 2025

  Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to; a.) follow the physician order with regard to application of an ointment and b.) ensure the skin assessment was accurate and completed in accordance with professional standards of practice and facility's policy and procedure, for 1 of 21 residents (Resident #8) reviewed.This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. […]

• No harm, potential for more than minimal, isolatedF756Jul 24, 2025

  Based on interviews, record review, and a review of pertinent facility documents, it was determined that the facility's Consultant Pharmacist (CP) failed to identify irregularity for 1 of 21 residents (Resident #8) reviewed. This deficient practice was evidenced by the following: On 7/16/25 at 10:50 AM, the surveyor observed Resident #8 seated in a wheelchair with a leg rest and left leg immobilizer in use. The surveyor also observed an IV (intravenous) pole. The resident stated that they had an order for IV ABT (antibiotic) daily, on skilled nursing for their infected left surgery, and rehabilitation (rehab). […]