Adroit Care Rehabilitation and Nursing Center

Inspectors wroteComplaint #: 3131839Based on observation, interview and record review, it was determined that the facility failed to; a.) notify the resident's physician to ensure that there was a physician order to discharge a resident and b.) notify the resident's legal guardian (LG) about discharge planning to ensure sufficient preparation for a safe and orderly discharge from the facility. This deficient practice was identified for 1 of 3 residents, (Resident #2) reviewed for discharge process. The deficient practice was evidenced by the following: A review of the admission Record (AR) revealed that the resident was admitted to the facility with diagnosis which included but not limited to: [...]

Inspectors wroteBased on observations, interviews, and record review on 5/6/26, it was determined that the facility failed to ensure that a cognitively impaired resident (Resident #1), who required care assistance, was free from verbal abuse by staff. This deficient practice was identified for 1 of 2 residents reviewed for abuse. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that food stored in residents' personal refrigerators was maintained in a safe and sanitary manner by failing to a.) ensure thermometers were present in residents' personal refrigerators to monitor internal temperatures, b.) routinely monitor and document refrigerator temperatures on a temperature log, c.) maintain food items at the appropriate internal temperatures, d.) discard food items in accordance with manufacturers' expiration or by the used by dates, and e.) routinely monitor and clean refrigerators. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to provide residents with a clean environment by failing to a.) appropriately dispose of soiled materials and personal protective equipment (PPE) and b.) provide clean bed linen and incontinence supplies maintained in sanitary condition to prevent cross-contamination. This deficient practice was identified in room [ROOM NUMBER] and Resident #16 reviewed for environmental concerns and was evidenced by the following:1). On 3/18/2026 at 11:19 AM, surveyor #1 toured room [ROOM NUMBER] and observed the following: Enhanced Barrier Precautions (EBP) signage posted on the door. Soiled materials including bed linen with other items wrapped inside and a blue disposable chuck) disposed of on top of the garbage receptacle. [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of pertinent facility documentation, it was determined that the facility failed to ensure residents receiving enteral feedings were provided appropriate care and services to prevent complications by failing to complete formula labels for residents receiving feedings. This deficient practice was identified for 2 of 3 residents (Residents #49 and #114) reviewed for tube feeding. The deficient practice was evidenced by the following:1.) On 3/18/26 at 11:24 AM, Surveyor #1 observed Resident #114 lying asleep in bed while receiving a continuous tube feeding (TF). Observation revealed that the TF bag was not labeled with the resident's name, room number, date and time the feeding was initiated, or the prescribed infusion rate per hour. Surveyor #1 reviewed the electronic medical record (EMR), for Resident #114. [...]

Inspectors wroteREPEAT DEFICIENCYBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store medications securely inside the medication cart by keeping it locked when unattended and b.) failed to ensure that medications were stored under proper temperature controls by failing to maintain unopened insulin vials in the refrigerator. The deficient practice was identified in 2 of 5 medication carts (B side 2nd floor cart and the 2nd floor central medication cart) observed during tour of the facility and medication storage and labeling task inspection. The deficient practice was evidenced by the following: A.) On 3/18/2026 at 9:09 AM, during the initial tour of the facility, Surveyor #1 observed a medication cart labeled B- Side unlocked along the B side hallway of the 2nd floor. The lock of the cart faced the hallway. [...]

Inspectors wroteBased on observations, interviews, review of medical records and other pertinent facility documents, it was determined that the facility failed to use appropriate infection control practices to prevent the spread or reduce the risk of infection in accordance with the Center for Disease Control & Prevention (CDC) guidelines and standards of clinical practice by ensuring, a.) respiratory device tubing, masks, and mouthpiece were stored in protective covering between uses identified for 1 of 5 residents (Resident #50) reviewed for respiratory care, b.) proper use of personal protective equipment (PPE) for 1 of 1 residents reviewed under contact precautions (Resident #75). [...]

Inspectors wroteComplaint: 2600629, 2601350Based on interviews, review of medical records, and review of other pertinent facility documentation on 8/29/2025 and 9/02/2025, it was determined that the facility failed to a.) implement a resident's (Resident #1) comprehensive care plan for out on pass with escort only which resulted in the resident eloping and b.) develop a care plan for a resident post elopement. On 8/22/2025, Resident #1 was sitting outside the facility unescorted and was found wandering on a multi-lane highway by a passerby who brought the resident to the police precinct and had a syncopal episode (loss of consciousness) and was transferred to the emergency room. This deficient practice was identified for 1 of 3 sampled residents (Resident #1) and was evidenced by the following: [...]

Inspectors wroteComplaint: 2600629, 2601350Based on interviews, medical records review, and review of other pertinent facility documentation on 8/29/2025 and 9/02/2025, it was determined that the facility failed to report a resident elopement to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 3 sampled residents (Resident #1) and was evidenced by the following: According to Resident #1's admission Record (AR), the resident was admitted to the facility with diagnoses that included but was not limited to: vascular dementia with mood disorder (commonly known as memory and thinking problems caused by poor blood flow to the brain along with mood changes). [...]

Inspectors wroteComplaint: 2600629, 2601350Based on interviews, review of medical records, and review of other pertinent facility documentation on 08/29/2025 and 9/02/2025, it was determined that the facility failed to follow acceptable standards of nursing practice by a.) not documenting a physician's order for a resident (Resident #1) to leave the facility on pass (out on pass) and b.) not following a physician's order for a psychiatric consultation and psychological consultation for a resident (Resident #1) that was ordered at admission to the facility. This deficient practice was identified for 1 of 3 sampled residents (Resident #1) 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 wroteCOMPLAINT #NJ185510 Based on interviews, record reviews, and review of other facility documentation, on 05/08/25 and 05/09/25, it was determined that the facility failed to provide a requested medical record for a discharged resident within 2 days of a written request. This deficient practice was identified for 1 of 3 residents, reviewed (Resident #6), and was evidenced by the following: Resident #6 was not at the facility at the time of the survey. A closed record review was conducted. According to the Resident Face Sheet, Resident #6 was admitted to the facility with diagnoses which included but were not limited to: Alzheimer's Disease, Dementia, Respiratory Disorder, and Chronic Pulmonary Obstructive Disease. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain a clean and sanitary environment for 2 of 2 shower rooms. The deficient practice was evidenced by the following: On 11/06/2024 at 10:58 AM, the surveyor entered the shower room on the second floor and observed tiles on the floor and various hygienic products left in the whirlpool tub. On 11/07/2024 at 09:49 AM, the surveyor entered the shower room on the second floor and observed tiles picked up and placed on the window sill, and items remained in the whirlpool tub. On 11/07/2024 at 1:05 PM, the surveyor entered the shower room on the third floor and observed brown stains on the wall and floor tiles, an empty can of aftershave on the floor, a leaking shower head in a plastic bag, and a broken faucet. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide a resident's activities of daily living (ADL) care in a dignified manner. This deficient practice was identified for 1 of 3 residents reviewed for activities of daily living (Resident #102), and was evidenced by the following: On 11/07/2024 at 10:58 AM, the surveyor observed Resident #102 in their private room accompanied by Certified Nursing Assistant (CNA #1), who assisted the resident transfer from a wheelchair to the bed. While laying in bed, the surveyor observed CNA #1 remove Resident #102 pants exposing the resident's lower body and their incontinence briefs. At that time, the surveyor left and asked the RN Supervisor-in-training (RN #1) to check on Resident #102. Upon returning to the room, Resident #102 was under the blankets and covered. [...]

Inspectors wroteComplaint # NJ00176124 Based on observations, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain treatment records that were complete with staff signatures according to professional standards of clinical practice for Resident # 72, 1 of 24 residents reviewed for professional standards. The deficient practice was evidenced by the following: A review of Resident # 72's admission Record indicated Resident # 72 was admitted to the facility with diagnoses which included but were not limited to Quadriplegia (partial or total loss of function in all for limbs and the torso) and Peripheral Vascular Disease (a condition that occur when blood vessels outside the brain and heart narrow, reducing blood flow to organs and tissues). [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that expired vaccines were removed from active inventory upon expiration. The deficient practice was identified in 1 of 2 medication rooms and was evidenced by the following: On [DATE] at 11:30 AM, in the presence of the Licensed Practical Nurse Unit Manager (LPNUM #1), the surveyor inspected the second floor medication room on the sub-acute unit. In the refrigerator, the surveyor observed a brown bag that had identification stickers which identified it as Covid-19 vaccines with an expiration date of [DATE]. Inside the bag were five (5) prefilled Intramuscular (IM) Moderna Covid 19 vaccine syringes with an expiration date of [DATE]. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide a sanitary and comfortable environment that helped prevent the development and transmission of communicable diseases and infections. The deficient practice was evidenced by the following: On 11/06/24 at 10:58 AM, upon initial tour of the second-floor sub-acute unit, the surveyor observed room [ROOM NUMBER] with an Enhanced Barrier Precautions sign along the doorframe. The surveyor observed inside the room Personal Protective Equipment (PPE) Gown discarded in the resident's personal trash bin. On the same date and time, the surveyor observed room [ROOM NUMBER] with a Contact Precautions Sign along the doorframe. The surveyor observed inside the room a discarded Personal Protective Gown on the resident's floor. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to a.) accurately obtain a blood pressure and accurately document the site, b.) accurately document the refusal of medications, d.) dispose of medications in a safe manner, c.) clarify and accurately administer a medication (Midodrine) according to a physician's order and d.) remove and dispose of controlled substances from active inventory when discontinued from March of 2023 until surveyor inquiry. The deficient practices occurred for two (2) of seven (7) residents, (Resident #56 and #75) reviewed for medication management and for two (2) of two (2) medication refrigerators inspected. Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide a homelike and dignified dining experience to residents on 2 of 2 nursing units on 3 consecutive days. The deficient practice was evidenced by the following. The surveyor observed the lunchtime meal at the following locations and days/times: Second floor dining room - 8/28/23 at 12:00 PM; 8/29/23 at 12:17 PM; 8/30/23 at 11:57 AM. Third floor dining room - 8/28/23 at 11:45 AM; 8/29/23 at 12:19 PM; 8/30/23 at 12:00 PM. During each of the observations, staff served residents' meals on plastic trays. The trays remained in place throughout the residents' mealtime. Additionally, staff placed each plate dome lid upside down on residents' tables and used them as a trash container for wrappers and debris from the meal tray. The dome lids remained in place on the tables throughout the mealtime. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete quarterly and comprehensive Minimum Data Set (MDS) assessments in a timely manner for 5 of 23 residents reviewed (Resident #8, #39, #89, #100 and #254). The MDS is an assessment tool used to guide the resident's plan of care. This deficient practice was evidenced by the following: 1. On 8/30/23 the surveyor reviewed the MDS Summary for Resident #8 which revealed the following. The annual MDS indicated an observation end date or assessment reference date (ARD) of 7/21/23. The status of the annual MDS was listed as in progress. The MDS should have been completed by the 14th day (8/4/23). The MDS was 26 days overdue on the day of the surveyor's record review (8/30/23). 2. On 8/30/23 the surveyor reviewed the MDS Summary for Resident #39 which revealed the following. [...]

Inspectors wroteComplaint # NJ00155894 Based on interviews, review of medical records and other facility documentation, it was determined that the facility failed to develop a comprehensive, person-centered Care Plan (CP) to address the needs for a resident with Diabetes, Epilepsy (a disorder that causes seizures), and that required oxygen (Resident #104), 1 of 24 residents reviewed for CP. This deficient practice was evidenced by the following: According to the admission Record, Resident #104 was admitted to the facility in May of 2022, with diagnoses that included but were not limited to: traumatic subdural hemorrhage (caused by a blow to the head or fall, causing bleeding inside the brain), Epilepsy, dependence on supplemental oxygen, and Type 2 Diabetes Mellitus. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure a physician's order for oxygen therapy was complete and thorough for 1 (#254) of 1 resident reviewed for respiratory services. The deficient practice was evidenced by the following: On 8/29/23 at 9:30 AM, the surveyor observed resident #254 in his/her room awake, alert, and oriented in bed. The oxygen concentrator was turned off and had no tubing or nasal cannula attached. The water reservoir was dated 8/26/23. On 08/30/23 at 11:53 AM, the surveyor interviewed the resident. The resident was pleasant and interviewable. The oxygen concentrator at the bedside was turned off and had no tubing or nasal cannula attached. On 08/30/23 12:15 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) assigned to the resident. [...]

Inspectors wroteBased on observation, interview, 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 observation on 8/30/23, the surveyor observed two (2) nurses administer medications to five (5) residents. There were 31 opportunities, and six (6) errors were observed which calculated to a medication administration error rate of 19.3%. This deficient practice was identified for two (2) of five (5) residents, (Resident #56 and #83), that were administered medications by one (1) of two (2) nurses that were observed. The deficient practice was evidenced by the following: 1. On 8/30/23 at 8:00 AM, during the morning medication pass, the surveyor observed the Licensed Practical Nurse (LPN #1) obtaining a blood pressure (BP) for Resident #56. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to (a). properly label, store and dispose of medications in two (2) of five (5) medication carts inspected, b). failed to secure two (2) of two (2) narcotic lock boxes in 2 of 2 medication refrigerators inspected, and c). failed to secure medications in one (1) of five (5) and in one (1) of four (4) treatment carts observed. This deficient practice was evidenced by the following: a). On [DATE] at 11:10 AM, the surveyor inspected the 3rd floor medication cart A in the presence of Licensed Practical Nurse (LPN#1). [...]