Ashbrook Care & Rehabilitation Center

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to protect Resident #43, as well as all residents from abuse, when on 5/7/25, an alert and oriented resident (Resident #43) with a history of being abused, informed the surveyor that they reported an allegation of sexual abuse to staff that was not investigated. This deficient practice occurred for 1 of 4 residents reviewed for abuse (Resident #43). On 5/6/25, Resident #43 informed Surveyor #1 that they [the residents] were having a problem with me because I am gay, some residents were afraid of me and some of the nurses made me touch them, I have not seen them. [...]

Inspectors wroteRefer to F 600 and F 610 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of sexual abuse after Resident #43 reported to the Registered Nurse/Unit Manager (RN/UM #1) that sometime at the end of December 2024 or January 2025, their buttocks was inappropriately touched by two female staff members. This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident #43). On 5/6/25, Resident #43 informed Surveyor #1 that they [the residents] were having a problem with me because I am gay, some residents were afraid of me and some of the nurses made me touch them, I have not seen them. [...]

Inspectors wroteRefer to F 600 & F 609 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to initiate and complete a thorough investigation for an allegation of sexual abuse, after a resident (Resident #43) informed staff that two female staff members inappropriately touched their buttocks. This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident #43). On 5/6/25, Resident #43 informed Surveyor #1 that they [the residents] were having a problem with me because I am gay, some residents were afraid of me and some of the nurses made me touch them, I have not seen them. [...]

Inspectors wroteRefer F 600, F 609, F 610 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by a.) ensuring all residents were protected from abuse; b.) ensuring an allegation of sexual abuse was thoroughly investigated; and c.) reporting an allegation of sexual abuse to the New Jersey Department of Health (NJDOH). This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident #43). On 5/6/25, Resident #43 informed Surveyor #1 that they [the residents] were having a problem with me because I am gay, some residents were afraid of me and some of the nurses made me touch them, I have not seen them. [...]

Inspectors wroteComplaint # NJ 173967 REPEAT DEFICIENCY Based on observation and interview, it was determined that the facility failed to ensure the environment and common areas were maintained in a clean, homelike and sanitary manner. The deficient practice occurred on 2 of 2 resident units (North and South) and in the main dining room/activity room and was evidenced by the following: [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to store all potentially hazardous foods at appropriate temperatures and maintain the kitchen environment and equipment in a clean and sanitary manner to limit the potential for food borne illness. The deficient practice was evidenced by the following: On 05/04/25 at 6:29 AM, the surveyor completed a brief initial tour of the kitchen with the [NAME] and observed the following: 1. The can opener affixed to the metal table had embedded debris on the base, blade and metal shavings were visibly embedded in the debris and the insert on the base of the can opener. 2. [...]

Inspectors wroteSurveyor: [NAME] Complaint NJ # 173967 Based on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to consistently provide appropriate Activities of Daily Living (ADLs) care, for residents who were dependent on staff assistance for care, by failing to provide: a) incontinence care, and b) nail care. This deficient practice was identified for 5 of 5 residents reviewed for ADL care (Resident #14 , #30, #31, #15 and Resident #33).

Inspectors wroteBased on observation, interview, record review, and review of pertinent documents, it was determined that the facility failed to ensure; a) Peritoneal Dialysis (PD - a procedure using the lining of the abdomen to filter out waste products from the blood) supplies were not stored directly on the floor in the room to avoid possible contamination; b) facility staff were trained and received competencies in PD; and c) staff were documenting the administration of PD. This deficient practice was identified for 1 of 1 resident (Resident #229) reviewed for PD and was evidenced as follows: A review of the admission Record (an admission summary) revealed that Resident #229 was admitted with diagnoses which included but were not limited to; End Stage Renal Disease, dependence of renal dialysis, and pneumonia. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain a medication error rate below 5%. On 5/4/25 at 8:09 AM, 2 surveyors observed 2 nurses administered 25 doses of medication to 3 residents and there were 2 errors which resulted in a medication error rate of 8%. The deficient practice was evidenced by the following: On 5/4/25 at 8:09 AM Surveyor #1 observed the Registered Nurse (RN ) on the South Wing, administered the following medications to Resident #15: Pantoprazole 40 mg 1 tab medication to treat Gastroeosophageal reflex. Dutasteride 0.5 mg 1 tab medication to treat benign prostatic hyperplasia Metropolol 25 mg 1 tab,medication to treat hypertension Miralax 17 gm, medication to treat constipation. Verapamil 120 mg 1 tab medication to treat hypertension. Apixiban, 5 mg, ( not administered). medication to treat blood clot. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to consistently follow medication hold parameters according to the physician's order. This deficient practice was identified for 1 of 3 residents reviewed for medications (Resident #1). The deficient practice was evidenced by the following: On 5/6/25 at 11:05 AM, the surveyor observed Resident #1 sitting in their bed. The Certified Nurse Aide (CNA) was present in resident's room. On 5/7/25 at 11:53 AM, the surveyor reviewed Resident #1's electric medical records (EMR) which revealed the following: The admission Record (AR; admission summary) revealed that Resident #1 had diagnoses which included but were not limited to: hypertension (high blood pressure), dementia and type 2 diabetes. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to dispose of refuse in a manner to maintain a sanitary environment and prevent potential pests. The deficient practice was evidenced by the following: On 5/4/25 at 7:05 AM, the surveyor observed the dumpster area with the Food Service Director (FSD) and observed the garbage dumpster door was open and filled with garbage bags and the recycling dumpster was also open. The area adjacent to the dumpster had various debris, pallets, old garbage cans and various debris including various plastic, paper, and pallets were strewn in the wooded area behind the dumpster. The FSD stated the dumpsters should be closed and the area should not look like that and proceeded to close the dumpster doors. [...]

Inspectors wroteBased on interviews and review of other facility pertinent documents, the facility failed to have a designated licensed Director of Nursing (DON) on a full time basis to oversee the care of all residents in the facility with 114 licensed beds. This failure increased the risk that all residents would not be provided with appropriate and accurate care and assessments from March 1, 2023, through July 10, 2023. This deficient practice was evidenced by the following: On 12/01/23 at 9:33 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA), Assistant Director of Nursing (ADON), and the Infection Preventionist Nurse (IPN). The LNHA stated that the facility had 114 licensed beds. The ADON stated that she had been at the facility for three months. [...]

Inspectors wroteBased on interviews and a review of pertinent facility documents, it was determined that the facility failed to provide oversight by a licensed Consultant Pharmacist (CP), to review the resident's medication regimen and medical record to identify and report irregularities for 17 out of 20 residents, (Residents #1, #11, #16, #17, #18, #24, #26, #38, #39, #43, #56, #61, #65, #72, #76, #87, and #90) reviewed during Medication Regimen Review (MRR), according to facility's policy and procedure. This deficient practice was evidenced by the following: 1. On 12/01/23 at 9:12 AM, the surveyor observed Resident #1 sitting on edge of bed eating breakfast and dressed appropriately. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide the residents with a safe, comfortable, clean, and homelike environment. This deficient practice was identified in 11 out of 17 resident rooms and one (1) of one (1) shower room observed during environmental rounds. This deficient practice was evidenced by the following: On 12/05/23 at 10:39 AM, the surveyor observed the wound care treatment of Resident # 39 that was done by the Licensed Practical Nurse (LPN) and was assisted by the Registered Nurse/Unit Manager (RN/UM). The LPN performed handwashing inside the toilet room, the toilet room was adjoined (a toilet room that is accessed from and used exclusively by the occupants of two adjacent sleeping units) and the toilet tissue paper holder dispenser was broken. [...]

Inspectors wroteComplaint # NJ00164563 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a) evaluate and complete an assessment for a newly identified pressure ulcer/injury (PU) for one (1) of two (2) residents reviewed for pressure ulcer/injury (Resident #299) according to standards of clinical practice and facility's policy and procedure, b) accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for one (1) of two (2) residents reviewed for PU (Resident #299), c) update the individualized care plan (CP) for one (1) of two (2) residents reviewed for PU (Resident #299), d) clarify multiple treatments for PU for one (1) of two (2) residents reviewed for PU (Resident #299), e) ensure all incident reports were in the computer system in order to track and trend, and [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that the facility failed to maintain the necessary respiratory care and services of residents who were receiving oxygen, according to the standard of practice, specifically a) that a resident received oxygen as ordered for three (3) of five (5) residents reviewed for respiratory care (Resident #11, #56, and #90) and b) oxygen and respiratory equipment were stored in accordance with facility policy and infection control measures for three (3) of five (5) residents reviewed for respiratory care (Resident #11, #65 and #90). This deficient practice was evidenced by the following: According to the National Library of Medicine, Oxygen-induced hypercapnia: [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure a) that Temporary Nurse Aides (TNA) were enrolled in school prior to 5/11/23 and completed their Certified Nurse Aide (CNA) certification by 9/11/23 as mandated by Centers for Medicare and Medicaid Services (CMS) and New Jersey Department of Health (NJDOH) in order to continue to work after 5/11/23 for two (2) of two (2) non-certified NAs reviewed that were previously working as TNAs; [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to a) develop and evaluate policy and procedure for the implementation of pharmaceutical services consistent with state and federal requirements and reflect current standards of practice for dispensing; disposing of narcotic medications within the electronic back-up machine (EBM) upon the departure of the previous Medical Director, and b) maintain a system of record keeping of the DEA Form 222 that ensured an accurate inventory and reconciliation of controlled dangerous substance (narcotics medications, with high potential for abuse and are tracked with detail) observed during medication storage inspection. This deficient practice was evidenced by the following: 21 CFR 1301.52 Termination of registration; transfer of registration; [...]

Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility failed to ensure a) that a consistent coordination/communication was provided between facility staff and hospice staff to meet the resident's needs b) that a recommendation made by hospice was acted upon on a timely manner (Resident #11), and c) an order was transcribed in accordance with standards of practice (Resident #65). This deficient practice was identified for two (2) of two (2) residents reviewed for hospice and end of life care. This deficient practice was evidenced by the following: 1. On 12/01/23 at 11:40 AM, during the initial tour, the surveyor observed Resident #11 in bed with the Oxygen (O2) concentrator on and set between 5 and 6 liters per minute (LPM). The resident was awake and conversant. [...]

Inspectors wroteBased on interview and review of pertinent facility documentation, the facility failed to have: a) the Director of Nursing (DON) present for two (2) of three (3) Quality Assurance and Performance Improvement (QAPI) meetings and b) the Infection Preventionist Nurse (IPN) present for one (1) of three (3) QAPI meetings. The deficient practice was evidenced by the following: On 12/13/23 at 11:04 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) in the presence of the survey team for an interview regarding the facility's QAPI program. The LNHA informed the survey team that the facility had a quarterly meeting and the key people to attend were the Medical Director, Infection Preventionist, LNHA, DON, Social Worker, Minimum Data Set (MDS) Coordinator, Dietary, and Housekeeping. [...]

Inspectors wroteBased on the interview and review of medical records, it was determined that the facility failed to consistently treat resident personal finances and resident mail in a respectful and accountable manner. This deficient practice was observed for one (1) of the 20 residents reviewed (Resident #17). This was evidenced by the following: On 12/01/23 at 12:00 PM, the surveyor requested a line list of the facility's Personal Needs Account (PNA) and the surety bond account information. On 12/06/23 at 9:07 AM, the surveyor observed Resident #17 in bed getting ready to be washed and bathed by his/her assigned hospice aid. The surveyor reviewed the medical records of Resident #17. [...]

Inspectors wroteComplaint #NJ00165614 #NJ00165821 Based on interviews, a review of medical records (MR), and other facility documentation, it was determined that the facility failed to report an allegation of neglect to the New Jersey Department of Health (NJDOH) in the required timeframe for one (1) of two (2) sampled residents, (Resident #17). This deficient practice was evidenced by the following: On 12/02/23 at 10:00 AM, the surveyor asked the Licensed Nursing home Administrator (LNHA) for a copy of Resident #17's Incident/Accident and Reportable (I/A & R) reports for the last eight (8) months, and the LNHA stated that he will get back to the surveyor. A review of the Complaint/incident investigative report revealed an allegation of neglect; [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately complete and update a Preadmission Screening and Resident Review (PASARR) to include all psychiatric diagnoses to ensure the resident was referred to the appropriate state-designated authority for level II PASARR evaluation and determination. This deficient practice was identified for one (1) of (2) two residents (Resident #18) reviewed for level II PASARR and was evidenced by the following: On 12/01/23 at 10:41 AM, during the initial tour, the surveyor observed Resident #18 laying in bed, alert, awake, covered with a bed sheet from chest to toe, and floor mats that were placed on both sides of the bed. The surveyor reviewed the medical record for Resident #18. [...]

Inspectors wroteBased on observation, interview, and review of medical records and facility documents, it was determined that the facility failed to update the resident's plan of care with new interventions. This deficient practice was identified for one (1) of 20 residents (Resident #17) reviewed for behaviors and assistance of daily living (ADL) and was evidenced by the following: On 12/06/23 at 9:07 AM, the surveyor observed Resident #17 in bed getting ready to be washed and bathed by his/her assigned hospice aid. The surveyor reviewed the medical records of Resident #17. Resident's admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observations, interviews, record review and review of other pertinent facility provided documentation, it was determined that the facility failed to ensure residents were appropriately supervised and monitored to ensure safety specifically by failing to ensure a) a resident was properly and accurately assessed for risk of elopement, b) a wander guard (a bracelet or anklet that triggers alarms and can have the capability to lock monitored doors to prevent a resident from leaving a facility unattended) was in place according to risk for elopement, c) a care plan for wandering was created, and d) the Minimum Data Set (MDS; an assessment tool used to facilitate the management of care) was accurately coded for one (1) of two (2) residents reviewed for elopement (Resident #26). This 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 the 24-hour staffing report that was posted was up to date and in a prominent place within the facility readily accessible to the residents and the visitors. This deficient practice was evidenced by the following: On 12/01/23 at 8:50 AM, the survey team entered the facility and observed the Nursing Home Resident Care Staffing Report (NHRCSR) was on a bulletin board outside the Licensed Nursing Home Administrator's (LNHA) office which was on the North unit side of the building. The location of the bulletin board was not visible to residents or their visitors that resided on the South unit since those residents and/or their visitors would not walk in that direction. The NHRCSR was dated 11/30/23. The NHRCSR for that day was not posted. [...]

Inspectors wroteBased on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure: a) the staff handled, stored, and processed linens and other supplies in a clean manner and to prevent possible contamination according to facility's policy and Centers for Disease Control and Prevention (CDC) guidelines, b) routine, ongoing, and systematic monitoring and tracking of facility's water management, and c) policy was reviewed and updated to reflect and address the need of the facility according to clinical standard of practice and CDC guidelines. This deficient practice was evidenced by the following: According to the CDC, Appendix D - Linen and laundry management, last reviewed May 4, 2023, Best practices for management of clean linen: [...]

Inspectors wroteBased on interviews, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the implementation of a comprehensive antibiotic stewardship program (ASP) in accordance with the facility's policy and procedure and the Centers for Disease Control and Prevention (CDC) guidance. This deficient practice was identified for one (1) of one (1) month antibiotic (ABT) log reviewed. This deficient practice was evidenced by the following: According to CDC, Core Elements of Antibiotic Stewardship for Nursing Homes, Page last reviewed: August 20, 2021, included, . Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. [...]

Inspectors wroteBased on the interview and review of pertinent facility documents, it was determined that the facility failed to ensure that the designated Infection Preventionist (IP) dedicated solely to the infection prevention and control program (IPCP), and physically worked onsite in the facility for one (1) of two (2) staff and b) must have time necessary and participate in required Quality Assessment and Assurance (QAA) committee for one (1) of three (3) QAPI quarters in accordance with the facility policy and Centers for Medicare and Medicaid Services (CMS) and New Jersey (NJ) guidelines. This deficient practice was evidenced by the following: According to the NJ Executive Directive 21-012 (revised 12/22/22) included ii. [...]

Inspectors wroteBased on observation, interview, medical record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure a comprehensive care plan was developed for a resident who was receiving pain medication (Resident #18). This deficient practice was identified for 1 of 18 residents reviewed for care plans and was evidenced by the following: On 01/24/2023 at 11:30 AM, Resident #18 was observed awake and in bed. Resident #18 stated that the staff provided pain medication for the resident's pain. According to the admission Record, Resident #18 was admitted to the facility in 02/2013 with diagnoses which included but were not limited to; [...]