Asbury Park Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were followed for one of three sampled residents (Resident 1) when:Resident 1's PET/CT (Positron Imaging Tomography/Computed Tomography - an imaging test that combines metabolic data with detailed structural images) scan preparation was not followed as ordered by the physician; and,Resident 1 was transferred to a different hospital contrary to the physician-ordered hospital. These failures had the potential to result in complications during Resident 1's procedure, and had the potential to result in confusion regarding Resident 1's location for continuity of care.

Inspectors wroteBased on interviews and record reviews, the facility failed to administer medication for one of four sampled residents (Resident 1) when Resident 1's ordered medication, Propranolol hydrochloride (Propranolol HCl, a medication that helps slow down the heart and reduce the effects of stress hormones on the body), was not available during medication administration. This failure had the potential to cause Resident 1 to experience worsening tremors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for two of 30 sampled residents (Resident 18 and Resident 62) when:1. Resident 18's call light was not within reach and was not appropriate; and,2. Resident 62's call light system was not appropriate. This failure placed Resident 18 and Resident 62's safety at risk and had the potential for the residents' needs to be not met.

Inspectors wroteBased on interview, and record review, the facility failed to provide appropriate treatment and services to maintain or improve mobility and prevent decline in range of motion (ROM) for one out of 30 sampled residents (Resident 13) when Resident 13's restorative nursing program (RNA program- interventions that actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning) frequency was not followed. This failure had the potential for Resident 13 to experience a decline in range of motion or impairment in mobility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 30 sampled residents (Resident 147) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's orders when Resident 147's pain medication orders were not consistently followed. This failure had the potential for Resident 147 to experience unrelieved pain and/or over-medication and not attain her highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure strict controls were maintained for the accounting, storage, and documenting of controlled substances (medications with high potential for abuse and addiction under strict government control) as evidenced by:Medication physical inventory counts did not reconcile with the controlled substance record (CSR, for an inventory count sheet to record usage of controlled medications) for six medications for Residents 149, 155, 125, 166, and 133 during an inspection of two out of three medication carts sampled. Discontinued controlled substances remained stored in one of two medication refrigerators and one of three medication carts sampled for Residents 163,165,50, 69, 15 and 7. [...]

Inspectors wroteBased on observation, interview and record review the facility had a medication error rate of 6.45% when four medication errors occurred out of 62 opportunities during the medication administration for three out of nine residents observed (Residents 9, 157 and 112). Resident 9 received a dose of cholecalciferol (Vitamin D3 supplement, used to prevent or treat Vitamin D deficiency) 25 times greater than prescribed. Resident 157 received the wrong dose of Humulin R (Regular Insulin, a short acting insulin used to lower blood sugar), and the ordered dose of Humulin N (NPH Insulin, an intermediate acting insulin providing basal coverage) was not administered. Resident 112 received acetaminophen (an over the counter medication to reduce fever and mild pain) not in accordance with the prescribed pain level. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and diagnostic agents were properly labeled according to manufacturer guidelines when:Several opened and undated medications, and one opened and undated container of glucose test strips, were observed stored in 2 of 3 medication carts sampled. One opened and undated Forteo pen (pre filled injection device used to deliver specialty medication to treat osteoporosis, a condition of weakened bones), was observed stored in 1 medication room refrigerator of two medication rooms sampled. This failure had the potential for residents to receive ineffective, expired, or unstable medications, and for staff to use expired or inaccurate glucose test strips when monitoring residents' blood glucose levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety when:Three dietary staff did not wear hair and beard restraints; andOne dietary staff did not practice hand hygiene between soiled and clean dishes during the dishwashing process. These failures had the potential to result in food contamination which could cause illness for 132 residents who received food prepared from the facility kitchen. During an observation on 3/24/26 at 8:30 and 11:00 a.m., Dietary Aide (DA) 2 wore a beanie in the kitchen without a hair restraint and hair was exposed in the back and sides of the head. DA 1 and [NAME] (CK) 1 had beards without beard restraints during food preparation. During an interview on 3/24/26 at 8:45 and 11 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program when;1. A facility staff did not wear required personal protective equipment (PPE) when providing high contact care and handling the indwelling catheter (a thin, hollow tube that is inserted into the bladder to drain urine and is left in place for a period of time) for one out of 30 sampled residents (Resident 130) who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use);2. Money was stored in a medication cart, creating a risk for cross contamination of medications, and3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer insulin (a medication used to lower blood sugar) according to the sliding scale in a timely manner (a set of instructions for administering insulin dosages based on specific blood glucose readings) when the insulin was administered more than 2 hours after the blood glucose reading for one of nine residents observed during the medication pass (Resident 157). This failure created the potential for inaccurate dosing and adverse effects from uncontrolled blood sugar.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 30 sampled residents (Resident 160) received care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when Resident 160's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) bag was left on the floor. This failure had the potential for Resident 160 to develop infection and possible urinary catheter complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for a census of 134 residents, when flies were observed in the residents' rooms. This failure decreased the facility's potential to maintain a pest free environment for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was promoted for one of three sampled residents (Resident 1), when the resident was left with a soiled brief for an extended period of time. This failure had the potential to result in Resident 1 not attaining his highest practicable social, physical, mental and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to protect 3 of 6 sampled residents (Resident 2, Resident 4, and Resident 6) from abuse by peer residents for a census of 136 when; 1. Resident 1 slapped Resident 2 in the face; 2. Resident 3 punched Resident 4 in the Thigh; and, 3. Resident 3 expressed verbal slurs to Resident 6. This failure resulted in 3 sampled residents being abused by peer residents and had the potential to cause physical injury and negatively impact their psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menu or spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) was followed for the therapeutic diets during the lunch meal distribution on 1/8/25 when: 1. 20 residents (Resident 16, 17,18, 26, 28, 41, 44, 47, 60, 62, 64, 71, 80, 82, 92, 98, 100, 101, 110, and 386) with CCHO (control carbohydrate) diets (diet uses for person with diabetes and maintain a stable sugar level throughout the day) with regular portion received margarine instead they should not receive margarine, 2. Two Residents (Resident 34 and 37) with CCHO, Renal (refer to the kidney) diet (diet that manage a person with diabetes and kidney disease) did not receive baked fish and/or wheat roll but they should have as indicated on the spreadsheet, 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety when: 1. The ice machine was not clean, 2. Various sizes kitchenware in the clean and ready-to-use storage areas: a. Were stacked and stored wet b. Had food particles 3. An air gap was not found on the food production sink, 4. Dietary Aide (DA) 1 did not verbalize the process of manual dishwashing correctly, 5. [NAME] (CK) 1 and CK 2 had beard and did not have beard restraint. These failures had the potential to result in food contamination which could cause illness in 128 out of 128 medically vulnerable residents who received and consumed food from the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean environment for the residents and visitors when one of two garbage dumpsters, located outside the facility, was not closed securely with the dumpster lids. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for three out of four residents (Residents 58, 65, and 69) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 31 sampled residents (Resident 7, Resident 128, and Resident 25) were free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 7 received Seroquel (an antipsychotic to treat mental illness) without implementation of non-pharmacological (non-drug) interventions in an effort to lower the dose or discontinue the medication; and 2. Resident 128 received Seroquel without an adequate indication for its use. 3. Resident 25's behavior order was different from the behavior being monitored for the use of Lorazepam (anti-anxiety medication) and there was no documented evidence of non pharmacological interventions used when behavior occurred. These failures had the potential to result in unnecessary use of medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rate was not 5% or greater when the error rate was 12.5% based on four medication errors out of 32 opportunities observed during a medication pass for three of five residents (Resident 12, 104, and 110). These failure resulted in medications not given in accordance with the prescriber's orders or manufacturer's specifications and potential to affect the resident's clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: -Medications were stored in accordance with manufacturer specifications; -Opened medications were dated with an open and discard date, to ensure they were not used beyond the discard date; -Expired and discontinued medications were disposed of in accordance with facility policy and procedure (P&P); -Medication carts were kept clean and orderly and single resident multidose medications were appropriately labeled with resident specific labels to ensure they were used for the right resident; -Controlled medications (those with high potential for abuse or addiction) were stored in accordance with facility P&P; and -Medication carts were kept securely locked when left unattended. - Resident 81's inhaler was observed at the resident's bedside. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services furnished by outside resources had written agreements when three out of 31 sampled residents' (Resident 15, Resident 36, and Resident 51) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) services were provided without existing agreements with dialysis clinics. This failure had the potential to result in the lack of responsibility and accountability in the dialysis services received by Resident 15, Resident 36, and Resident 51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 132 when: 1. Resident 36's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was observed on the floor when not in use; 2. Resident 46's nasal cannula was observed on the floor when not in use; 3. Dust particles were observed on the vents above the clean linen area and dust particles and moisture were observed at the back of the washers in the laundry room; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the building and equipment were maintained in a functional and operable manner when pipes in the laundry room were dirty, corroded, and leaking. This failure had the potential to result in the facility not providing safe and sanitary handling of laundry items used by residents for a census of 132.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consents were obtained from authorized resident representative for one of 31 sampled residents (Resident 97) when Resident 97's consent to treat, Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), and psychotropic medication (drugs that affect brain activities associated with mental processes and behaviors) consents were not signed by Resident 97's Responsible Party (RP). This failure increased the potential for Resident 97's RP to not be informed of the risks and benefits of treatment and medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and keep secure, when not in use, confidential resident health data and records for a census of 132. This failure had the potential to expose and disclose personal and confidential health information to unauthorized individuals.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of bed hold for one of 31 sampled residents (Resident 15) when Resident 15 was transferred to the hospital and Resident 15's Responsible Party (RP) was not provided written notice of bed hold for return to the facility. This failure had the potential for Resident 15's RP to not be informed of Resident 15's right to return to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of quality as stipulated by their admission policy and procedure to ensure accuracy of admission medications for one of 31 sampled residents (Resident 487) when a psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication order was not carried over upon admission. This failure resulted in Resident 487 not receiving psychotropic medication for eight days and increased the potential for Resident 487 to experience emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 31 sampled residents (Resident 51) received necessary foot care when toenails were long and thick. This failure increased the potential for Resident 51 to experience pain and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure an ongoing communication and collaboration for the development and implementation of the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care plan by the facility and dialysis staff for one of 31 sampled residents (Resident 36), when Resident 36' s anemia (a condition where the body does not have enough healthy red blood cells) medication was not communicated with the dialysis clinic and was signed as given at dialysis. This failure resulted in the facility not being aware of Resident 36's current anemia management and decreased the facility's potential to monitor Resident 36 for the medication's effectiveness and side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist (CP) identified and reported to the facility irregularities related to the medication regimen for one of 31 sampled residents (Resident 128) during the Medication Regimen Review (MRR). This failure resulted in inadequate monitoring and had the potential for medications not being optimized for best possible health outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the special dietary requirement for two residents (Resident 106 and 108) during the lunch observation on 1/7/25. This deficient practice had the potential to result in meal dissatisfaction and decreasing meal intake that may lead to further compromising medical and nutrition status and/or weight loss of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failure to ensure a call light (a device used by a resident to signal the need for help) were accessible for 2 of 31 sampled residents (Resident 22 and Resident 82), when Resident 22 and Resident 82 were not physically able to use the call light provided when it was out of reach. These failures had the potential to result in unmet resident needs and delayed staff response.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify that one of three sampled residents (Resident 1) left facility without staff awareness or physician order for Leave of Absence (LOA), when Resident 1 left facility with unidentified person and was not known to have left facility until he returned to the facility on his own. This failure resulted in Resident 1 going to an unsafe environment with risk for harm and injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow and maintain an effective Infection Prevention and Control Program (IPCP) for a census of 134 residents when: 1. A facility staff did not wear required personal protective equipment (PPE) while providing catheter care for Resident 1, who was on Enhanced Standard Precautions (ESP- also known as Enhanced Barrier Precaution/EBP). 2. Resident 1, Resident 2, and Resident 3, who were on ESP, did not have required PPE readily available outside the room. These failures resulted in increased risk for cross-contamination (transfer of bacteria from one person, object, or place to another) and may cause infections among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote individual care and dignity, when the staff failed to respond to three of five sampled residents (Resident 1, Resident 2, and Resident 5), who needed assistance with personal care and the staff did not answer their call lights in a timely manner. This failure resulted in the residents' needs not being met, they experienced discomfort, embarrassment, and felt helpless.

Inspectors wroteBased on interview and record review, the facility failed to report the result of the 5-day investigation within the required timeframe for two residents (Resident 1 and Resident 2) when Resident 1 scratched Resident 2. This failure decreased the facility's potential to provide appropriate corrective actions to safeguard the health and safety of the residents.

Inspectors wroteBased on observation, interview and documentation review, the facility failed to ensure a safe environment for the residents, staff, and the public when the evacuation routes were cluttered with carts, bedside commode, linen bins, and garbage bins in a 139-bed facility. This failure caused Resident 4 to feel unsafe in the facility and increased the potential for a delay in an evacuation should an emergent situation arise that would have the facility use this evacuation route.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of care when the physician order for one of three sampled residents (Resident 1) was not implemented according to the facility's policy and procedures. This failure resulted in Resident 1 to have received a thickened liquid diet despite the physician order and/or the resident's preference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) had access to water. This failure resulted in Resident 1 to be thirsty and increased the potential for dehydration, urinary tract infection, pneumonia, skin infections, confusion and disorientation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory infection control practices were promoted for one of three sampled residents (Resident 1) when the resident's nasal cannula (a plastic tubing that supplies oxygen to the resident through their nostrils) was found on the floor and the tubing was dated 1/18/24. These failures place Resident 1 at increased risk for respiratory infections who had already compromised lung capacity.

Inspectors wroteBased on interview, record review, and facility policy and procedure review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect, when Resident 1 complained that a staff member cut her hair against her wishes. This failure caused Resident 1 to feel upset and distressed.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of quality for one of 3 sampled residents (Resident 7) when nursing staff did not follow the physician's order for foley catheter (a tube inserted through the urethra to drain urine from the bladder) care. This failure resulted in Resident 7 having multiple urinary tract infections (UTIs) within two months of admission to the facility and was sent to the acute care hospital (ACH) with severe sepsis and acute organ dysfunction (the body's extreme reaction to infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to intervene in a timely manner to prevent an abrupt weight loss for one of 3 sampled residents (Resident 1) when she had a pattern of meal refusals and lost 14.9 pounds (lb) in one month. This failure resulted in Resident 1 having an unplanned weight loss (14.9 lbs ) in one month and had the risk potential to have caused the resident's inability to fight infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper infection prevention and control practices were maintained during a Covid-19 (respiratory disease caused by a virus and spread from person to person) outbreak when four staff did not properly don (put on) PPE (personal protective equipment- mask/N95 respirator). This failure had the potential to result in the spread of infections among residents and staff.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, the facility failed to timely address a resident concern of missing prescription glasses for 1 (Resident #94) of 26 sampled residents.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure 1 (Resident #470) of 4 sampled residents reviewed for food was not provided dairy products.

Inspectors wroteBased on observation, interview and record review, the facility failed to adhere to professional standards of practice for one of 3 sampled residents (Resident 1) when baclofen (drug used for muscle spasms) was ordered for him without consideration of his kidney failure. This failure had the potential risk to result in drug toxicity.