Mcauley Hall Health Care Cente

In the surveyor’s words

From the most serious findings on record at Mcauley Hall Health Care Cente, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Aug 12, 2025

  Based on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness and, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following:On 8/5/25 at 11:00 AM, in the presence of the Food Services Director (FSD), the surveyor observed the following:1. In the food preparation area, the surveyor observed a handwashing sink, which was attached to a stainless-steel food preparation area and there was no partition between the sink and food preparation surface.2. […]

• No harm, potential for more than minimal, widespreadF868Mar 13, 2024

  Based on the interview and record review, it was determined that the facility failed to ensure that the Infection Preventionist (IP), Director of Nursing (DON), Medical Director (MD), or designee attended the quarterly Quality Assurance (QA) meetings. This was identified for three (3) of the three (3) quarterly QA meetings reviewed. This failure had the potential to affect all 68 residents who currently live in the facility. The deficient practice was evidenced by the following: The surveyor reviewed the QA meeting sign-in sheets for the last three (3) quarters dated June 30,2023, September 30, 2023, and January 12, 2024. The sign-in sheets for those three (3) quarters revealed no DON signatures to show that the DON was in attendance for June 30, 2023, and January 12, 2024, QA meetings. […]

• No harm, potential for more than minimal, patternF686Mar 13, 2024

  Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) maintain infection control practices to reduce the risk of infection during a pressure ulcer (PU) treatment; b.) follow a physicians order during a PU treatment; c.) follow the recommendations of the wound care center physician; and d.) assess and document the measurements of the PU one (1) of two (2) residents reviewed for PU (Resident #39). This deficient practice was evidenced by the following: On 3/06/24 at 11:13 AM, the surveyor observed that Resident #39's door had a stop sign that indicated the resident was on enhanced barrier precautions. […]

• No harm, potential for more than minimal, patternF755Mar 13, 2024

  Based on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to: a.) maintain a system of record keeping of DEA (Drug Enforcement Administration) Form-222 (a federal narcotic requisition form used for ordering controlled substances), that ensured drug records were in order, and controlled dangerous substance (narcotics medications), with high potential for abuse were tracked with detail to enable prompt identification of loss or potential diversion of controlled substance; and b.) develop a policy and procedure for narcotic medications which included record keeping of DEA Form-222. […]

• No harm, potential for more than minimal, patternF921Mar 13, 2024

  Complaint# NJ154270 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain: a) the residents' patio in a safe and homelike condition for one (1) of two (2) patios, b) the laundry area in a safe and sanitary condition, and c) a safe and sanitary environment in one (1) of three (3) kitchenettes in accordance with the facility procedures and federal regulations, and were identified during the environment tour of the facility. This deficient practice was evidenced by the following: 1. […]