Acclaim Rehabilitation and Nursing Center

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 3/31/25 at 9:14 AM, the surveyor in the presence of the Food Service Director (FSD) observed the following during the kitchen tour. 1. In walk-in refrigerator #1, the surveyor observed a blackish dust like substance in the gasket. 2. The surveyor observed on the 3-spout coffee machine a hard water build up on top of machine and on the first coffee spout had a brownish sticky substance on the spout. 3. The surveyor observed puddle of water below the hand washing, the water was coming from a leaking pipe. 4. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure (a). that a medication was administered according to the physician orders (PO) and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in 1 (one) of 8 (eight) residents (Resident #34) observed during the medication observation pass and (b), to follow acceptable standards of clinical practices for accurately administering medications according to PO. This deficient practice was identified in 1 (one) and 7 (seven) residents (Resident #10 ) reviewed for medication administration. The deficient practice 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 observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to develop and implement smoking policies in accordance with state law and regulations to provide smoke-free air which prohibits indoor smoking in healthcare facilities. This deficient practice was observed for 1 of 1 designated smoking areas and was evidenced by the following: Reference: N.J.A.C. 8:6 Smoke-Free Air prohibits smoking in most workplaces as well as in indoor public areas. It included a list of all of the indoor public places and workplaces where smoking was banned, which included healthcare facilities. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to notify the resident's representative in writing for an emergency transfer to the hospital. This deficient practice was identified for 2 of 2 residents, Resident #101 and #105 reviewed for hospitalization. On 04/1/25 at 4:06 PM, the surveyor reviewed the electronic medical records for resident #101. A review of Resident #101's face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; asthma (chronic resp9iatory disease which the airway narrows and swells mking it difficult to breath), hypertension (the force of the blood against the artery walls is too high) and anemia (low red blood cells). [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) in accordance with federal guidelines. This deficient practice was identified for 6 (six) of 28 residents (Resident #3, #10, #29, #47, #68, and #138) reviewed. This deficient practice was evidenced by the following: The MDS is a comprehensive tool federally mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of completing the assessment. After the MDS is transmitted, a quality measure will be transmitted to enable a facility to monitor the residents' decline or progress. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse by another resident for four of four residents (Resident (R)19, R83, R26, and R74) reviewed for abuse in a total sample of 34 residents.

Inspectors wroteBased on observations, record review, interviews, and facility procedure review, the facility failed to ensure that two (Resident (R)3 and R114) of the 34 sampled residents were treated with dignity and respect that promotes enhancement of quality of life.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to assist one resident (Resident (R)50) of the total 34 residents sampled in obtaining dentures.

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to provide full visual privacy during medication administration and during a physical examination for 2 of 22 residents reviewed, Resident # 14 and Resident # 81. The deficient practice was evidenced by the following: 1. On 6/2/21 at 10:21 AM, the surveyor observed the Registered Nurse (RN) lift the right pant leg of resident #14 and apply a pain patch on the right knee in the hallway while residents and staff were walking around the area. On 6/4/21 at 10:56 AM, the surveyor spoke with the resident about the observation of the nurse putting the pain patch on their knee in the hallway. The resident stated Yes, he did, I came out of the shower that day. The surveyor asked the resident if the nurse always put the pain patch on in the hallway. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide a safe environment to prevent a fall during the repositioning and care of a resident. The deficient practice occurred for 1 of 2 residents (Resident #62) reviewed for falls and evidenced by the following: On 6/2/21 at 12:23 PM, the surveyor observed Resident #62 in bed with eyes closed. The resident had a tracheostomy and was receiving oxygen. There was a floor mattress on either side of the bed. The surveyor reviewed Resident #62's medical records that revealed the following: According to the admission Record, Resident #62 was admitted to the facility with diagnoses that included Traumatic Brain Injury and Respiratory Failure. [...]

Inspectors wroteBased on observation, interview and review of facility records, it was determined that the facility failed to ensure an accurate inventory of controlled medications (narcotic medications) was dispensed from the facility's narcotic back up cabinet. The deficient practice occurred in 1 of 1 back up narcotic boxes inspected and evidenced by the following: On 6/3/21 at 11:17 AM, the surveyor checked the back-up narcotic cabinet located in the Supervisor's office, in the presence of the Director of Nursing (DON). The package labeled Oxycod/APAP 10-325 mg (a combination narcotic pain reliever) had 9 tablets in the package. When compared to the declining inventory sheet, a discrepancy was observed. The declining inventory showed 10 Oxycod/APAP 10-325 mg tablets remaining in the package. The surveyor asked the DON to recount the tablets and she confirmed the same discrepancy. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection. This deficient practice was observed for 2 of 22 residents reviewed, Resident #81 and #103, as evidenced by the following: On 6/2/21 at 11:20 AM, the surveyor observed personal protective equipment (PPE) hanging on the door of Resident #81. There was also a STOP sign and a sequence for putting on and taking off PPE sign on the door which read droplet precautions, everyone must: clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry, wear N95 mask, put on gown and gloves, and remove face protection before room exit. [...]