Peace Care St Joseph's

In the surveyor’s words

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

• Actual harm, isolatedF686Aug 22, 2023

  Complaint # NJ00161813 Based on interview and record review it was determined that the facility failed to provide effective care and services to promote healing of a pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. Resident #105's right heel wound was left untreated for more than a month. During this period the wound's length doubled in size. The deficient practice was evidenced by the following: The surveyor reviewed Resident #105's closed hybrid medical record which revealed the following information. The Admission Record indicated the resident was admitted to the facility from the hospital on 12/5/22. […]

• No harm, potential for more than minimal, widespreadF812Apr 15, 2026

  Based on observation, interview, and record review, it was determined that the facility failed to: a) maintain kitchen equipment in a clean, safe and sanitary manner for 3 of 4 kitchenettes (2nd, 3rd, 4th), and b) maintain kitchen equipment in a clean, safe and sanitary manner 4 of 4 pantries (1st, 2nd, 3rd, 4th), on the nursing floors as evidenced by the following. On 4/09/26 at 11:50 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following on the nursing units:The kitchenette microwaves had multicolored food debris on the interior ceiling of the units for 3 of 4 units, (2nd, 3rd, and 4th). The FSD acknowledged and agreed that they were not cleaned according to facility policy. […]

• No harm, potential for more than minimal, patternF755Nov 7, 2024

  Based on observation, interview, record review and review of other facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure, a.) consistent maintenance of the system of record keeping of the Drug Enforcement Agency (DEA) order Form-222 (a federal narcotic requisition form), that enabled accurate reconciliation of controlled-dangerous substances (narcotic medications, that due to their high potential for abuse, are tracked with a degree of detail and attention) that was ordered and received, b) the development and implementation of policy and procedure for DEA order Form-222, c) removal and disposition of a discharged Resident's medication from the active inventory, and d.) properly label… […]

• No harm, potential for more than minimal, patternF868Nov 7, 2024

  REPEAT DEFICIENCY Based on interview and record review, it was determined that the facility failed to assure that the required staff attended the quarterly Quality Assurance (QA) meetings. This was identified for 4 of 4 quarterly QA meetings reviewed. This deficient practice was evidenced by the following: On 10/31/24 at 10:00 AM, upon entrance conference, the surveyor requested to review the QA meeting sign in sheets for the last few quarters of QA meetings held. On 11/4/24 at 10:30AM, the surveyor received QA meeting sign in sheets dated, 10/17/24, 7/18/24, 4/18/24 and 1/18/24, which revealed that the Infection Preventionist (IP) was not in attendance for any of those scheduled meetings. […]

• No harm, potential for more than minimal, patternF880Nov 7, 2024

  Based on observation, interview, and record review it was determined that the facility failed to a) maintain infection control standards and procedures during wound care treatments for 2 of 5 residents (Resident #181, #6) reviewed for care and services for pressure ulcers, b) provide a safe and sanitary environment to prevent the potential spread of infection and cross-contamination to both residents and staff by sharing personal care items between residents and a linen cart which contained linen for multipe residents was brought into a Resident room (room [ROOM NUMBER]) and then back out into the hallway, observed for 1 of 3 CNAs (CNA #1) on 1 of 4 nursing units, (4th-floor unit) and c) failed to practice acceptable hand hygiene as recommended by the CDC. […]