Peace Care St Ann's

In the surveyor’s words

From the most serious findings on record at Peace Care St Ann's, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF838Mar 9, 2026

  Based on the interview and review of facility documentation, it was determined that the facility failed to ensure that facility wide assessment included the resources required to establish policies and procedures for the management of staffing contingency plans in order to meet the requirements and needs of all residents in the facility. This failure had the potential to affect all 107 residents who currently live in the facility.This deficient practice was evidenced by the following:During the entrance conference on 3/3/26 at 10:08 AM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) a copy of the Facility Assessment (FA). […]

• No harm, potential for more than minimal, widespreadF812Nov 22, 2022

  Based on observation, interview, and review of pertinent facility documentation, it was determined that: a.) the facility failed to store and serve potentially hazardous foods in a manner to prevent food borne illness in 3 of 3 Bistros, and b.) failed to maintain refrigerator temperatures and store food at the correct temperature for 1 of 3 Bistro refrigerators. This deficient practice was evidenced by the following: On 10/31/2022 at 10:46 AM, in the presence of the first floor Registered Nurse/Unit Manger (RN/UM) the surveyor observed the following: The surveyor observed on the first floor Bistro: 1.) The refrigerator had a clear, small bin that housed pre-sliced bologna deli meat wrapped in clear plastic wrap. […]

• No harm, potential for more than minimal, patternF584Mar 9, 2026

  Based on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified for 2 of 3 units (2nd and 3rd floors), 2 of 3 Residents rooms (room [ROOM NUMBER] and room [ROOM NUMBER]), and common areas (3rd floor family room, 2nd and 3rd floors dining rooms, 2nd and 3rd floors Bather, 2nd and 3rd floors hallways, and 2nd floor soiled utility room) and was evidenced by the following:The deficient practice was evidenced by the following: 1.On 3/3/26 at 10:18 AM, Surveyor #1 (S#1) observed the 3rd floor Certified Nursing Assistant (CNA) charting area on the low side, the desk with peeling wood on the lower drawer. […]

• No harm, potential for more than minimal, patternF607Mar 9, 2026

  Based on interview and review of pertinent facility documents, it was determined that the facility failed to verify the credentials and substantiated findings for staff in the Criminal Background Screening Report and reference checks prior to date of hire in accordance with the facility's abuse policy and procedure for the screening of newly hired employees. This deficient practice was identified for 9 of 79 newly hired employees (Staff #24, #33, #42, #43, #56, #64, #69, #71, and #78) as evidenced by the following: 1.On 3/5/26 at 1:20 PM, Surveyor #1 (S #1) reviewed total of 30 new employee files and revealed: A review of Staff #24's file, a Recreation Aide, with a date of hire (DOH) of 7/9/25, revealed a criminal background screening report (CBSR) dated 7/22/25. […]

• No harm, potential for more than minimal, patternF628Mar 9, 2026

  Complaint NJ#2616278Based on interviews, record review, and review of facility provided documents, it was determined that the facility failed to provide information to the resident or the Resident Representative (RR) that explains the Bed Hold and Reserve Bed Payment policy. This deficient practice was identified for 3 of 3 residents, (Resident #11, #129, and #132), reviewed for discharge process.The deficient practice was evidenced by the following: 1. A review of closed medical records revealed that Resident #132 had an acute transfer on September 2025 due to diagnoses of hypernatremia (high sodium concentration in the blood) and sepsis (serious condition in which the body responds to an infection). […]