Accela Rehab and Care Center at Manalapan

Inspectors wroteCOMPLAINT #2963689, 2978806 Based on interviews, review of medical records and other pertinent facility documentation on 5/28/26 and 5/29/26, it was determined that the facility failed to develop a comprehensive care plan to address the resident's discharge plans. This deficient practice was identified for 6 residents reviewed (Resident #1, Resident #2, Resident #4, Resident #5, Resident #6, and Resident #7) and was evidenced by the following:1.) A review of the admission Record revealed that Resident #1 was admitted to the facility with diagnoses that included but were not limited to: chronic kidney disease, hypotension, and mild cognitive impairment. A review of Resident #1's care plan did not reveal a focus related to the resident's preference and potential for future discharge. [...]

Inspectors wroteCOMPLAINT #2963689, 2978806 Based on interviews, record review, and review of facility documentation on 5/28/26 and 5/29/26 it was determined that the facility failed to a.) keep resident's medical information confidential and b.) follow facility policy titled Release of Information on maintaining the confidentiality of residents' information. The deficient practice was identified for one resident reviewed (Resident #6), and was evidenced by the following:A review of the admission Record revealed that Resident #6 was admitted to the facility with diagnoses that included but were not limited to: metabolic encephalopathy, secondary parkinsonism, and dementia. Further review revealed that the resident's address and that of their two contacts including phone numbers, were included in the resident's admission form. [...]

Inspectors wroteComplaint #: 2708219Based on interviews, review of medical records, and review of other pertinent facility documents on 1/8/2026, it was determined that the facility failed to obtain a physician's order for oxygen therapy, upon admission, for a resident that was identified as needing continuous oxygen therapy. This deficient practice was identified for 1 of 3 residents reviewed (Resident #3), as evidenced by the following:According to the admission Record (AR), Resident #3 was admitted with diagnoses that included but were not limited to: pneumonia and acute respiratory failure with hypoxia. According to the Minimum Data Set (MDS), an assessment tool, Resident #3 did not have a Brief Interview for Mental Status (BIMS) score completed at the time of survey due to recent admission. [...]

Inspectors wroteComplaint #: 2708219Based on interviews, review of medical records, and review of other pertinent facility documents on 1/8/2026, it was determined that the facility failed to develop and implement a baseline care plan to address a resident's oxygen therapy and failed to address the resident's known non-compliance with oxygen use. This deficient practice was identified for 1 of 3 residents reviewed (Resident #3), as evidenced by the following: According to the admission Record (AR), Resident #3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: pneumonia and acute respiratory failure with hypoxia. According to the Minimum Data Set (MDS), an assessment tool, Resident #3 did not have a Brief Interview for Mental Status (BIMS) score completed at the time of survey due to recent admission. [...]

Inspectors wroteComplaint # 2672054 Based on interviews, review of the Medical Records (MR), and pertinent facility documents on 12/9/25, it was determined that the facility Nursing staff failed to notify the Resident's family when a Resident had a change in condition for 1 out of 4 sampled residents (Resident #2). This deficient practice is evidenced by the following: According to Resident #2's MR, the Resident had diagnoses which included but were not limited to: Crohn's Disease and Ulcerative Colitis. According to the Minimum Data Set (MDS) an assessment tool utilized to facilitate the care of a resident, dated 10/31/25, indicated that Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12/15, indicating the Resident was moderately impaired. A review of Resident #2's Progress Notes (PN) documented by the Nursing Supervisor dated 11/01/25 at 9:50 AM, revealed: [...]

Inspectors wroteBased on review of Nurse Staffing Report sheets, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 1 of 28 days reviewed. This deficient practice was evidenced by the following:According to the Nursing Staffing Reports completed by the facility, the facility provided no RN services on 7/20/25. NJAC 8:39-25.2(h)

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a refrigerated controlled medication (Lorazepam oral concentrate solution) was removed from active inventory when the controlled medication was discontinued on [DATE] and when six (6) of the 15 Lorazepam oral syringes were expired on [DATE]. The deficient practice was identified when one (1) of two (2) medication room refrigerators were inspected and evidenced by the following: On [DATE] at 1:37 PM, the surveyor inspected the 200 Unit medication room refrigerator in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM). The surveyor observed six (6) of 15 oral syringes of Lorazepam oral concentrate 0.5 milligram per 0.25 milliliters labelled for Resident #30 with a use by date of [DATE]. [...]

Inspectors wroteBased on interviews and review of pertinent facility documents, it was determined that the facility failed to ensure the facility-wide assessment (used to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies) was updated to address the care and needs of a resident with a LVAD (a left Ventricular Assist Device-a mechanical pump that helps a weakened heart pump blood). On 8/7/2025 at 11:00 AM, during a resident council meeting, which included unsampled Resident #67 and two surveyors, Resident #67 stated they had a LVAD. The surveyor reviewed the electronic Medical Record for unsampled Resident #67. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain medical records that were accurate and easily accessible for 1 of 30 residents reviewed (Resident #116). This deficient practice was evidenced by the following:On 8/12/2025 at 8:41 AM, the surveyor reviewed the closed electronic medical record for Resident #116. [...]

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to complete the admission Minimum Data Set (MDS), a periodic and federally mandated, standardized assessment tool, within the required time frame. This deficient practice was identified for 1 of 2 residents (Resident #18) reviewed for timing of assessments and was evidenced by the following: This deficient practice was evidenced by the following: On 8/8/25, a review of the electronic health record (EHR) revealed that Resident #18 was admitted to the facility on [DATE]. The Comprehensive admission MDS, with an assessment reference date (ARD) of 2/27/25, was noted to be signed as completed on 3/18/25. On 8/8/25, the surveyor interviewed the MDS Coordinator who stated this admission MDS should have been completed by March 6th (3/6/25). [...]

Inspectors wroteBased on observation, interview, review of medical records, other facility documentation, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool, for 2 of 27 residents reviewed (Resident #10 and Resident #13). This deficient practice was evidenced by the following:1. On 8/6/25 at 11:54 AM, Resident #10 refused to speak with the surveyor. The resident refused to speak with the surveyor for the duration of the survey. On 8/12/25 at 10:59 AM, the surveyor interviewed Certified Nursing Assistant (CNA) #1, who stated that Resident #10 had specific CNAs that they want and only allowed them to provide care and would shout, yell, curse, and refuse everything for others. [...]

Inspectors wroteComplaint #401653, #401655Based on observation, interview and record review, it was determined that the facility failed to ensure medications were administered in accordance with professional standards of nursing practice. This deficient practice was identified for 3 of 7 residents reviewed for medication management, (Resident #9, #120 & #57), and was 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: [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication administration observation performed on 8/7/25, the surveyor observed two (2) nurses administer medications to five (5) residents. There were 35 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 8.57 %. The deficient practice was identified for two (2) of five (5) residents, (Resident #30 and #55), that were administered medications by two (2) of two (2) nurses. The deficient practices were evidenced as follows: 1. On 8/7/25 at 8:24 AM, the surveyor observed the Registered Nurse (RN) #1 administer four (4) medications to Resident #30. The resident then stated that they wanted their cough medicine. [...]

Inspectors wroteNJ401652Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to effectively accommodate the needs and preferences of residents during dining. This deficient practice was identified for 1 of 10 residents (Resident #43) reviewed for tray accuracy during dining and was evidenced by the following: On 8/6/25 at 10:34 AM, the surveyor observed Resident #43 lying in bed asleep, with the head of the bed elevated, on an air mattress. The resident did not respond when the surveyor knocked on the door or in response to verbal stimuli. The surveyor observed a sign that hung over the resident's bed which indicated, No Straws and Thickened liquids, do not leave thickener packets with the resident. The surveyor reviewed the medical record for Resident #43. [...]

Inspectors wroteNJ401661, NJ401667, NJ401652Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to follow appropriate infection control procedures during the provision of incontinence care for a resident who was previously identified to have been at risk for recurrent urinary tract infection. This deficient practice was identified for 1 of 1 resident (Resident #43) reviewed for bladder and bowel incontinence and was identified by the following: On 8/6/25 at 10:34 AM, the surveyor observed Resident #43 lying in bed asleep, with the head of the bed elevated, on an air mattress. The resident did not respond when the surveyor knocked on the door or in response to verbal stimuli. The surveyor reviewed the medical record for Resident #43. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to provide food that accommodated a resident's known food allergy to eggs and egg-derived products. This deficient practice was identified for 1 of 18 residents (Resident #32) reviewed for meal observations. On 02/27/24 at 8:32 AM, Resident #32 was observed eating a hard-boiled egg. The meal ticket on their breakfast tray had documented allergies to eggs and egg-derived products. This posed the likelihood of serious harm to the health and wellbeing of Resident #32. This resulted in an Immediate Jeopardy (IJ). The IJ was identified and began on 02/27/24 and the IJ template was given to the Licensed Nursing Home Administrator (LNHA) on 02/27/24 at 12:48pm. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent documents, it was determined that the facility failed to a) ensure adequate supervision to prevent falls, b) ensure current documented fall prevention interventions were consistently implemented, and c) ensure the Falls Policy was consistently followed to complete an assessment of the causal factor and identify and implement pertinent fall prevention interventions to prevent further falls, . This deficient practice was identified for 1 of 5 residents (Resident #5), reviewed for accidents. Resident #5 was identified as a fall risk for falls. Sustained 13 falls from 09/11/22 through 02/25/24, including falls with major injuries on 09/11/22 (72 hours after admission) sustained a hematoma to the right forehead and pain to the right shoulder. [...]

Inspectors wroteComplaint #s NJ 152910, 152911, 159956 Based on observation, interview and document review, it was determined that the facility failed to ensure that all residents were treated with respect and dignity by ensuring the facility acted promptly to respond to ongoing residents grievances affecting quality of life by failing to consistently and uniformly address grievances regarding: a) ensuring residents had consistent access to their personal needs account funds (PNA), b) food complaints identified on 02/28/2022 when the resident council was alerted to the menu being changed to kosher style, and c) the menu not being posted, not having access to menus to select meal choices and the repetitiveness of the menu. This deficient practice was identified by 6 of 6 residents who attended a resident council meeting and affected all residents who resided on 2 of 2 units. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to ensure that a system was in place for residents to receive their Personal Need Account (PNA) funds without restrictions, ensure that the residents had access to at least $50.00 which would be provided the same day it was requested, and ensure a system was in place which included receipts provided to residents to confirm disbursement. The deficient practice effected all residents who maintained PNA funds who resided in the facility. The deficient practice was evidenced by the following: Refer to 565F On [DATE] at 8:50 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the requested list of current PNA balances and stated that the Human Resources Director (HRD) was responsible for the PNA accounts. [...]

Inspectors wroteBased on interview and document review, the facility failed to have a system in place to ensure all residents who had the facility manage Personal Needs Account (PNA) funds were provided with a quarterly statement. The deficient practice effected all resident who had PNA funds and was evidenced by the following: Refer to 565F and 567F. On [DATE] at 8:50 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the requested list of current PNA balances and stated that the Human Resources Director (HRD) was responsible for the PNA accounts. The list included 94 accounts and listed 6 residents with a Current Balance more than $50.00 who were listed as Expired [deceased ] under Status. On [DATE] at 1:22 PM, the surveyor interviewed the HRD who confirmed that she handled the PNA money for the resident's accounts during the week. [...]

Inspectors wroteBased on interview and document review it was determined that the facility failed to have a process in place to ensure that within 30 days of a resident's death the facility conveyed, the resident's funds, and a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate. This deficient practice occurred for 6 of 6 expired residents identified with a current Personal Needs Account balance (Resident #236, #237, #238 and 3 unsampled residents) and was evidenced by the following: On [DATE] at 8:50 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with the requested list of current PNA balances and stated that the Human Resources Director (HRD) was responsible for the PNA accounts. The list included 94 accounts and listed 6 residents with a Current Balance who were listed as Expired [deceased ] under Status. [...]

Inspectors wroteComplaint # NJ 169440 Based on observation and interview it was determined that the facility failed to have a system in place to ensure all resident rooms and common areas were maintained in a clean, sanitary and homelike manner, and resident equipment was maintained in good condition. The deficient practice was observed throughout the 200 unit and was observed by the following: On 02/20/24 at 10:26 AM through 11:15 AM, surveyor #1 observed the following on the 200 Unit: -room [ROOM NUMBER], Resident in bed, a gray chair next to the bed was visibly stained on the seat cushion, the bed and bed frame appeared rusted, the bedside table had chips, and the privacy curtain was visibly soiled. -room [ROOM NUMBER] A, There was no handle on the middle drawer of the door side bedside table. [...]

Inspectors wroteComplaints NJ #s: 159956, 161569, 165971, 169440 Based on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to ensure that Activities of Daily Living Care (ADLs) was consistently provided to residents by failing to a.) provide appropriate incontinent care to dependent residents (Resident #6, #18, #22, #23, #31, #32, #38 #50, #51 #53 #55); and b.) provide residents with scheduled showers (Resident #233 and #80). This deficient practice occurred for 12 of 12 residents, 1 of 1 closed record (Resident #80) reviewed for ADLs, and 1 of 6 residents who attended a resident council meeting. The deficient practice was evidenced by the following: [...]

Inspectors wroteComplaint #s NJ 152905, 152910, 152911, 159956, 161569, 165971, 160660, 169440 Based on observation, interview and review of pertinent documents it was determined that the facility failed to ensure sufficient and competent staff were available to a) provide appropriate incontinence care to dependent residents (Resident #6, #18, #22, #23, #31, #32, #38, #50, # 51, #53 and #55), b) provide residents with scheduled showers (Resident #80 and #233), and c) ensure all residents were treated in a dignified manner. This deficient practice was identified for 12 of 12 residents, 1 of 1 closed record (Resident #80) reviewed for ADLs, expressed by 6 of 6 Residents who attended a Resident Council meeting, and affected all residents on 2 of 2 units. This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on interview and review of pertinent documentation, it was determined that the facility failed to ensure the designated licensed Director of Nursing (DON) worked on a full-time basis as DON to oversee the care of all residents in the facility. This deficient practice was evidenced by the following: On 02/21/24 at 11:34 AM, the DON stated that the previous facility Infection Preventionist (IP) was a corporate nurse who was covering multiple facilities. He stated that the facility had been interviewing candidates for the IP position, but they did not have enough experience or wanted a lot of money so he had been also performing the job as IP. On 02/22/24 at 11:02 AM, the DON in the presence of the survey team, confirmed his job was to be the full-time DON, but he was also working as the facility IP. [...]

Inspectors wroteComplaint # NJ # 160660 Based on observation, interview and document review it was determined that the facility failed to serve hot and cold foods at an appetizing temperature for 4 of 4 hot food items, 2 of 2 cold food items and for 6 of 6 residents who attended a resident council meeting. The deficient practice was evidenced by the following: On 02/22/24 at 8:44 AM, the last meal tray was tested for temperature by two surveyors utilizing a calibrated thermometer and the Food Service Director (FSD). The resident meal was labeled a Chopped Diet. Hot food items: -Chopped French Toast; FSD- 90 degrees Farenheight (F), Surveyor-88 F. -Sausage; FSD- 89 F, Surveyor -90 F. -Hot Cereal; FSD-132 F, Surveyor-129 F. -Coffee; FSD- 124 F. The surveyor asked the FSD what the hot food temperature should be, and he stated 140 F or above. Cold food items: -4 ounces skim milk; [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure a) foods were stored properly and labeled with a use by date, b) equipment was maintained in a clean and sanitary manner, and c) hair restraints were appropriately worn to prevent the spread of potential infection or food borne illness. The deficient practice was evidenced by the following: On 02/20/24 from 9:41 AM through 10:15 AM, the surveyor conducted an initial tour with the Food Service Director (FSD) and observed the following: The walk-in refrigerator contained: -A package of undated meat was in a plastic -type wrap, stored in a metal pan, on a shelf and was covered with aluminum foil. The FSD stated, sometimes they throw on a use by date and stated it was pulled from the freezer on 02/17/24 and it's beef stew for tomorrow. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility administration failed to ensure policies, procedures and effective systems were implemented to maintain each resident's highest practicable physical, mental, and psychosocial well-being by failing to ensure a) a resident with documented food allergies were provided with appropriate food items, b) that appropriate and timely incontinence care was provided to dependent residents, c) residents were treated with dignity and respect, d) residents were consistently provided with physician ordered medications, e) interventions were implemented to prevent falls for a resident with frequent falls with history of fractures, residents received appropriate incontinent care to limit urinary tract infections, f ) resident council grievances were addressed, e) residents resided in a homelike environment, g ) [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that medical record access was provided in a timely manner during an on-site survey conducted from 02/20/24 through 03/06/24. The deficient practice was evidenced the following: On 02/20/24 11:19 AM, the surveyor conducted an entrance conference with the Licensed Nursing Home Administrator (LNHA), the Director of Nursing (DON) and the [NAME] President of Nursing (VPON) from a management company. The VPON stated the management company was the company that was purchasing the facility. The surveyor asked about the electronic medical record (EMR) system the facility utilized and the LNHA stated they have a new EMR since November 2023. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility's Quality Assessment and Assurance Committee (QAPI) failed to ensure the facility self- identified areas for improvement including environmental concerns, resident care related concerns, the Antibiotic Stewardship Program and adverse events. This deficient practice had the potential to affect all residents that resided in the facility and was evidenced by the following: Refer to F550F, F565F, F567F, F584F, F677E, F689G, F690H, F742H, F806J, F890G 1.) During a tour of the 200 unit on 02/20/24 and 02/21/24, the surveyors observed several rooms with broken furniture, soiled privacy curtains, missing privacy curtains, dust in rooms and air conditioners cracked. [...]

Inspectors wroteBased on interview and the review of pertinent facility documentation, it was determined that the facility failed to have the a.) the Medical Director (MD) and the Infection Preventionist (IP) present for one (1) of four (4) quarterly Quality Assurance Performance Improvement (QAPI) meetings and b.) Infection Preventionist (IP) report on the Infection Prevention and Control Program (IPCP) for four (4) out of four (4) QAPI meetings reviewed. The deficient practice had the potential to affect all residents who resided in the facility and was evidenced by the following: a.) On 03/06/24 at 9:17 AM, the surveyor reviewed the last four (4) quarterly sign in sheets for the QAPI meetings. The sign in sheet dated 04/18/23 did not include the signature of the IP and the sign sheet dated 07/08/23 did not include a signature that the MD was in attendance. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to follow infection control practices to prevent the spread of potential infection by a) storing dirty meal trays apart from clean, not yet served, resident meals trays on 1 of 2 units; b) adhering to accepted standards of infection control practices for the proper storage of respiratory tubing and mask after use for 1 of 1 residents reviewed (Resident #31); c.) ensuring the ice scoop and ice scoop container were clean for 1 of 2 units; and d.) ensuring staff performed appropriate hand hygiene (HH). The deficient practice was identified on 2 of 2 units and evidenced by the following: 1. On 02/22/24 at 8:35 AM, Surveyor #1 went to the 200 Unit to observe the breakfast meal. [...]

Inspectors wroteComplaint NJ #159556 Based on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to ensure a.) 1 of 1 resident (Resident # 51) was reviewed for reoccurring Urinary Tract Infections (UTI), and b.) a facility-wide implementation of the Antibiotic Stewardship program, which included a system for routine feedback reports and tracking measures of outcome surveillance related to antibiotic use was followed, as per facility policy and national standards. This deficient practice was evidenced by the following: 1.) On 02/21/24 at 11:01 AM, the surveyor observed Resident #51 awake and alert sitting in his /her wheelchair in dining room eating lunch. A review of the Electronic medical record (EMR) revealed the following physician's orders (PO) and corresponding progress notes: [...]

Inspectors wroteBased on observations, interviews and document review, it was determined that the facility failed to ensure residents were treated with dignity and respect by failing to ensure a) resident requests for water were honored, b) meals were served in a dignified homelike manner without the use of disposable dishware, c) consistently communicated with residents by their preferred name and not label residents as feeders, d) staff did not speak in a foreign language in the presence of the residents, e) staff conducted personal phone calls during resident interactions, and f) all residents were provided with privacy curtains. The deficient practice was identified during a resident council meeting held with six residents, and evidenced during a survey conducted from 02/20/24 through 03/06/24, and affected all residents who resided on 2 of 2 resident units. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to develop and implement an individualized resident-centered comprehensive care plans with measurable goals: a) to integrate approaches for a resident with a history of aggression and exhibited behaviors, b) for a resident with a history of falls including falls with injury, c) and interventions for a resident who had a history of psychosis, and d) for a resident with allergies. This deficient practice was identified for 4 of 18 residents (Resident #1, #5, #76, and #32) reviewed for Care Plans (CP) and was evidenced by the following: a. On 02/20/24 at 12:34 PM, Surveyor #1 observed Resident #1 in bed with the lunch tray on the bedside table. [...]

Inspectors wroteComplaint NJ 161569, NJ 169440 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to ensure that the resident call bells were accessible. This deficient practice was identified for 3 of 18 residents (Residents #1, #78 and #288) reviewed for the call bells and was evidenced by the following: 1) During the tour of the facility on 02/20/24 at 10:04 AM, Surveyor #1 observed Resident #1 sitting in the bed. The resident responded to the surveyor's greetings then asked for a drink of water. The surveyor informed the resident that she was just a visitor and not staff and instructed the resident to activate the call light. The resident informed Surveyor #1 that [he/she] did not have a call light. The surveyor looked on the bed and on the floor and did not observe a call light. [...]

Inspectors wroteThe facility failed to ensure the required Minimum Data Set (MDS) assessments were submitted timely as evidenced by 1 of 1 resident reviewed (Resident #66) for a system selected MDS Record over 120 days old. The deficient practice was evidenced by the following: On 02/22/24 at 11:33 AM, the surveyor reviewed the MDS for Resident #66 and interviewed the Licensed Practical Nurse MDS coordinator (MDSC) regarding submission of the MDS. The MDSC stated she was not at the facility at that time and an old medical record system was utilized. The MDSC then viewed an MDS report on the old system and stated the quarterly MDS and discharge MDS did not appear to be submitted and she would research further. On 02/23/24 at 10:00 AM, the Licensed Nursing Home Administrator (LNHA) provided a report for Resident #66's Discharge Assessment scheduled as due no later than 09/14/23 which was Accepted. [...]

Inspectors wroteBased on interview, record review and document review, it was determined that the facility failed to ensure that an ongoing activity program was designed to meet the needs of all residents, specifically those who enjoyed outside of the facility trips. The deficient practice was identified for 1 of 2 residents reviewed for activities (Resident #18) and was evidenced by the following: On 02/29/24 at 9:00 AM, the surveyor reviewed the Electronic Medical Record for Resident #18, and reviewed the current Care Plan which did not include a care plan for activity preferences. The annual minimum data set (MDS) dated [DATE] revealed Resident #18 scored a 15 out of 15 on the Brief Interview for Mental Status, and was cognitively intact. The Interview for Activity Preferences revealed it was very important to go outside for fresh air when the weather was good. [...]

Inspectors wroteBased on observation, interview, review of medical records, and review of other pertinent documentation, it was determined that the facility failed to ensure residents received pain management consistent with professional standards of practice and physician's orders. This deficient practice was identified for 2 of 2 residents (Resident #75 and #286) reviewed for pain and was evidenced by the following: 1.) On 02/20/24 at 9:31 AM, the surveyor observed Resident #75 lying in bed awake and alert. Resident #75 stated that his/her back had been hurting. He/she stated that Tylenol (medication used to relieve mild to moderate pain) helps some. He/she further stated that he/she used to get a patch on their back but not for a while. A review of the admission Record revealed that Resident #75 had diagnoses which included but were not limited to; [...]

Inspectors wroteComplaint #159956 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to develop and implement interventions to prevent urinary tract infections (UTIs) for a resident with a history of chronic UTI's (from 06/17/2022 through 01/03/2024) which required oral and intravenous (IV) antibiotic therapy, and required hospitalization. This deficient practice was identified for 1 of 2 Residents (Resident #51) reviewed for Urinary Tract Infections and was evidenced by the following: On 02/23/24 at 6:15 AM, Surveyor #5 completed an incontinence care tour on the 200 Unit, a strong urine odor permeated in the hallway of the low side of the 200 Unit. Surveyor #5, in the presence of a Certified Nurse Aide (CNA #1), observed Resident # 51 was wearing two incontinent briefs that was saturated with urine. [...]

Inspectors wroteComplaint NJ #s 154702, #154763 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a) antipsychotic medications were administered daily per physician orders for two residents, Resident #19 who missed 8 daily doses, and Resident #45 who missed 9 daily doses. This resulted in increased combative and hallucinatory behaviors that necessitated transfer to Crisis via 911 (emergency) for both residents, and b) behaviors were monitored and documented and appropriate interventions were developed and implemented for Resident #76 who required antipsychotic medication. This deficient practice was identified for 2 of 3 residents (Resident #19 and #45) reviewed for change in condition and for 1 of 4 resident (Resident #76) reviewed for use of psychotropic medications. [...]

Inspectors wroteComplaint #s NJ 154702, NJ 154763 Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to notify a resident representative and/or physician for 2 of 3 residents reviewed for change in condition. This deficient practice was identified for Resident #19 and Resident #45 reviewed for a change in condition and was evidenced by the following: 1) Review of Resident #19's Medication Administration Record (MAR) revealed that Resident #19 did not receive Clozapine 100 milligrams (mg) as ordered by the physician for three consecutive days 03/18/22, 03/19/22, and 03/20/22. The resident did not receive the same medication on an additional three consecutive days 03/29/22, 3/30/22 and 3/31/22. There was no documented evidence that the resident's physician was notified of the resident not being administered the medication as ordered. [...]

Inspectors wroteComplaint # NJ 159956 Based on observations, interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order from the attending physician as recommended by the consulting podiatrist for a resident with a diabetic foot ulcer for 1 of 1 resident (Resident #51) reviewed for foot care. A review of the Electronic medical Record (EMR) revealed that Resident #51 was admitted to the facility with diagnosis including but not limited to: Type 2 diabetes mellitus, dementia, overactive bladder, urinary tract infection (UTI), acquired absence of left great toe and coronary angioplasty implant and graft (a treatment used to widen and open narrowed or blocked arteries supplying your heart muscle). [...]

Inspectors wroteBased on observations, interviews, and review of facility documentation, it was determined the facility failed to a.) maintain medications with appropriate labeling and b.) maintain a clean, orderly medication cart for 2 of the 3 carts observed on 2 of 2 nursing units. This deficient practice was evidenced by the following: On 11/18/21 from 11:19 to 11:54 AM, in the presence of the Registered Nurse (RN) #1, the surveyor observed the following in the medication cart labeled B on the 100 unit: 1. In the first row of the second drawer, there were two yellow oval tablets, one pink oval tablet, one large white oval tablet, one small white oval tablet, and one white round tablet which were unwrapped and unmarked. There was also paper debris. 2. [...]

Inspectors wroteBased on observation, interviews, and other facility documentation, it was determined that the facility failed to ensure that kitchen staff were properly trained and capable of performing assigned duties to maintain proper kitchen sanitation and prevent food-borne illness. This deficient practice was evidenced by: During the initial tour of the kitchen on 11/17/21 from 09:47 AM until 10:34 AM, the surveyor observed the following in the presence of the Director of Dining Services (DDS): During an interview with the surveyor at 10:16 AM, the DDS stated that a high temperature dish machine was utilized, and the required wash temperature was 150 degrees or higher and the required final rinse temperature was 180 degrees. [...]