Barnert Subacute Rehabilitation Center, LLC

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that resident receive treatment and care in accordance with professional standards of practice, by failing to ensure; a.) physicians' orders and approved plan of care were followed, b.) provider's (consultant) recommendation was followed through for 1 of 17 residents, (Resident #27), from March 2024 through April 2025, for a total of 13 months, and c.) routine Braden scale assessment was done for residents with history of facility acquired wounds, for 1 of 2 residents, (Resident #27), reviewed for pressure ulcer. This 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 interview, record review, and review of other pertinent facility documentation, it was determined the facility failed to ensure accurate documentation of a residents' advance directives for 2 of 3 residents, (Resident #15, Resident #16) reviewed. This deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid (electronic and paper) medical records of Resident #15, which revealed: A review of the admission Record (AR) (an admission summary) revealed that the resident was admitted with diagnoses that included but were not limited to, urinary tract infection and hypertension (high blood pressure). A review of the most recent discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, reflected a Brief Interview Mental Status (BIMS) score of 12 out of 15, which indicated the resident had moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to provide a safe, clean, and comfortable homelike setting. This deficient practice was identified in dining room for 2 of 5 days observation, and was evidenced by the following: On 4/17/25 at 8:25 AM, the surveyor observed the dining room (and recreation area) with no residents inside the room. The surveyor observed the floor with accumulation of grayish and blackish substances, pieces of small plastic wrapper and paper, and the tv (television) with accumulation of grayish substances. There was a bed at the end of the dining area with no cover, with stack of different chairs, the windowsill with accumulation of grayish substances, and the vending machine near the window with plastic with papers, and with accumulation of grayish substances. [...]

Inspectors wroteNJ#168277 Based on interview and review of facility documentation, the facility failed to provide and document sufficient preparation and orientation to resident to ensure safe and orderly transfer or discharge from the facility. This deficient practice was identified in 1 of 1 resident, (Resident #212), reviewed for discharge. The deficient practice was evidenced by the following: The surveyor reviewed the hybrid medical record (paper and electronic) for Resident #212. A review of Resident #212's admission Record (AR) (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited vertebral disc displacement (when a disc in the spine shifts and may cause pain) and difficulty walking. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility provided documentation, it was determined that the facility failed to a.) follow the physician's order with regard to medication with parameters for 1 of 4 residents, (Resident #44) and b.) ensure that the emergency cart (e-cart) was routinely check and supplies were not expired for 1 of 3 e-cart inspected, according to the standard of clinical practice and facility policy. This 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to ensure the accurate daily report of licensed nurses, certified nursing assistant staffing, and the resident census was posted at the beginning of the current shift for 1 of 5 days during the annual re-certification survey. This deficient practice was evidenced by the following: On 4/16/25 at 9:00 AM, the survey team entered the facility. The surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) posted at the front desk by the receptionist. The NHRCSR posted was dated 4/16/25 with a census of 60, for the [7:00 AM to 3:00 PM] day shift. On 4/16/25 at 9:30 AM, in the presence of the survey team, the admission Director, stated that the census (total number of residents) was 61. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for 1 of 5 residents reviewed for unnecessary medications, (Resident #33). The deficient practice was evidenced by the following: The surveyor reviewed Resident #33's electronic medical record (EMR) which revealed the following: A review of Resident #33's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to anemia, (a reduced number of red blood cells) and major depressive disorder (persistent depressed mood). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications (meds) were administered without error of 5% or more during medication (med) administration, 3 nurses administered meds to 5 residents. There were 26 opportunities for error, 2 errors were observed which calculated to a med administration error rate of 7.69%. This deficient practice was identified for 1 of 5 residents, (Resident #3), that was administered meds by 1 of 3 nurses that were observed. 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, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring, a.) that the Infection Preventionist Nurse (IPN) was aware in the facility's surveillance and monitoring of facility's water management according to standards of clinical practice, facility policy, and IPN's job description to prevent Legionella and other opportunistic waterborne pathogens to grow and spread and b.) the water management plan was implemented. This deficient practice was identified for 1 of 2 positive water testing results reviewed. This deficient practice was evidenced by the following: According to Centers for Disease Control & Prevention (CDC), Water Management in Healthcare Facilities, March 15, 2024, Key points: [...]

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 1 of 1 resident, Resident #60 reviewed for hospitalization. The deficient practice was evidenced by the following: On 2/21/23 at 11:50 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #60. The nurse progress notes revealed that the resident was transferred to the hospital on 1/25/23 at 2:45PM. According to the Discharge Minimum Data Set, an assessment tool used to facilitate the management of care dated 1/25/23, reflected that Resident #60 was discharged to the hospital with a return not anticipated to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain professional standards of practice to hold a medication used to treat high blood pressure in accordance with the physician's order (PO) for 2 of 2 residents reviewed, Resident #50 and Resident #59. The deficient practice is evidenced by the following: Reference: New Jersey Statuses Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and review of documentation provided by the facility, it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development of a food borne illness. This deficient practice was observed and evidenced by the following: On 2/15/23 at 10:00 AM, during the initial tour of the kitchen in the presence of the Food Service Director (FSD), the surveyor observed the following: At 10:20 AM, in the presence of the FSD, the surveyor observed the following in the walk-in refrigerator: 1. One fan covered with a heavy build up of a gray fuzzy substance. The FSD identified the substance as dust build up and acknowledged that the substance could dislodge from air blowing and go onto the food. 2. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices identified during 1 of 1 wound treatment observation for Resident #24. This deficient practice was evidenced by the following: On 3/8/21 at 10:38 AM, the surveyor observed the Licensed Practical Nurse (LPN#1) perform a wound treatment for Resident #24's hospital-acquired right heel wound; LPN #2 assisted LPN #1 with the positioning of the resident during the treatment. The surveyor reviewed the March 2021 Physician Order Summary, which reflected a Physicians' order (PO) to cleanse the right heel wound with ¼ strength Dakin's Solution, pat dry, apply Santyl, Mupirocin, Calcium Alginate Wound Dressing, and cover with a dry dressing daily. The PO was noted on the March 2021 Electronic Treatment Administration Record. [...]