Inspection Reports for
North Cape Center

The visit was complaint-related with multiple complaint numbers listed. The facility was found deficient in several areas including care planning, grievance resolution, staffing, infection control, and life safety. The complaints were substantiated as evidenced by the cited deficiencies.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long-term care facilities based on deficiencies in resident care planning, grievance resolution, mobility, respiratory care, infection control, meal service, and life safety code compliance. Multiple deficiencies were cited with severity levels ranging from SS=D (substantial compliance not met) to SS=E (immediate jeopardy not indicated).

The complaint investigation found that the grievance of Resident 151 was not resolved or documented, and that meals were consistently served late to residents on the second-floor secure unit, causing agitation and dissatisfaction.

The facility failed to provide a resolution to a grievance for one resident and failed to ensure timely meal service consistent with the meal schedule for residents on the second-floor secure unit, affecting residents' routines and preferences.

The facility was found deficient in multiple areas including failure to assess a resident's ability to self-care for a special treatment tube, failure to resolve resident grievances, incomplete care plans for oxygen and special treatments, improper application of splints, lack of physician orders for oxygen administration, delayed meal service affecting resident routines, improper storage of nebulizer masks, failure to implement enhanced barrier precautions for wound care, and improper medication handling by staff.

The facility was found deficient in multiple areas including staffing ratios, influenza vaccination record keeping for contracted employees, Mantoux testing for new employees, dining environment, transfer/discharge notification to Ombudsman, accuracy of assessments and care plans, accident hazard supervision, annual CNA performance reviews, pharmacy record keeping, food safety and sanitation, infection prevention and control practices including PPE use, antibiotic stewardship, and COVID-19 vaccination tracking for contracted staff.

The facility was found deficient in multiple areas including failure to create a homelike dining environment, inadequate notification to the State Ombudsman of resident transfers, inaccurate Minimum Data Set assessments, incomplete care plans for residents on intravenous antibiotics, unsafe smoking practices, lack of annual CNA performance evaluations, incomplete controlled substance documentation, unsafe food handling and storage practices, improper use of personal protective equipment by staff, inadequate antibiotic stewardship, and failure to track COVID-19 vaccination status of contracted staff.

The facility was found noncompliant with several Life Safety Code requirements including failure to provide 7 illuminated exit signs, improper mounting height of 4 portable fire extinguishers, failure to conduct annual electrical receptacle testing in resident rooms for 2022, and failure to perform 30-minute load tests on two emergency generators as required.

Complaint numbers NJ150129, NJ149266, and NJ147745 triggered the survey. The facility was found deficient in staffing ratios as substantiated by review of staffing reports and interviews.

The facility was found not in substantial compliance with New Jersey Administrative Code 8:39 for licensure of long-term care facilities, specifically failing to meet minimum staffing ratios for Certified Nursing Assistants (CNAs) and total staff on multiple shifts between August and November 2021. Staffing shortages potentially affected all residents.

The facility failed to implement physician orders for 3 of 21 residents reviewed, resulting in missing or delayed physician orders for treatments and medications. The facility provided education to staff and implemented audits to ensure timely transcription of orders.

The visit was complaint-related, triggered by concerns about failure to implement physician orders for oxygen, wound treatment, and catheter use. The report does not explicitly state substantiation status.

The facility failed to implement physician orders for 3 of 21 residents reviewed, including administering oxygen without a physician order, applying a prescribed cream without an order, and maintaining an indwelling urinary catheter without a current physician order. The facility acknowledged these deficiencies and provided education to staff on timely order transcription.