Berlin Rehabilitation and Healthcare Center

Inspectors wroteComplaint #: 3069904Based on interviews, record reviews, and review of pertinent facility documents on [DATE], it was determined that the facility failed to a) ensure that a cognitively impaired resident (Resident #2) was free from sexual abuse by a Certified Nursing Assistant (CNA #1), and b) implement their abuse policy to ensure all residents were free from sexual abuse. This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident #2). This resulted in an Immediate Jeopardy (IJ) situation and posed the likelihood of serious harm or injury to all residents. On [DATE], Resident #2's family member reported an allegation to Licensed Practical Nurse (LPN #1) and Social Worker (SW #1) that the resident had been sexually abused. The facility notified the police and Resident #2 was assessed for injuries. [...]

Inspectors wroteBased on interviews, review of medical records, and other pertinent facility documentation on [DATE], it was determined that the facility failed to provide adequate supervision to a cognitively impaired resident (Resident #2) with a known history of elopement who eloped from the facility on [DATE]. The deficient practice was identified for 1of 3 residents (Resident #2). The resident had a history of exiting their unit on [DATE]. On [DATE] at approximately 6:01 P.M., Resident #2, while wearing a wander guard (security bracelet), left their unit on the second-floor and exited the facility through the main lobby front door. Staff became aware that the resident was missing from their unit when another nurse informed Resident #2's Licensed Practical Nurse (LPN #1) that when a staff member was coming into the facility, he saw someone that looked like Resident #2 on the road. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure a.) the facility's four week cycle menus were consistently nutritionally adequate for fruit, protein, and starch servings in accordance with the facility provided Diet Manual and nationally accredited standards, b.) standardized recipes were readily available and followed, and c.) that all listed menu items were consistently provided at meals (Resident's #1, #28, #44, #81 and #88). This deficient practice was identified by surveyors during meal rounds on 3 of 3 units and was supported by 5 of 5 residents that attended the Resident Council Meeting on 5/20/25 (Resident's #8, #15, #50, #56 and #58). The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow Enhanced Barrier Precautions (EBP) during wound care and failed to follow proper hand hygiene practices during wound care for two of three residents (Residents (R) 11 and R12) reviewed for pressure ulcers out of 19 sampled residents. This failure had the potential to cause cross contamination and cause a wound infection.

Inspectors wroteNJ00166442 Based on interviews, review of closed medical records and other facility documentation, it was determined that the facility failed to consistently implement timely interventions in adherence with the facility pressure injury prevention policy and the resident's care plan to promote skin integrity and prevent the development of moisture-associated skin damage (MASD) of both the right and left buttocks, a deep tissue injury (DTI, an injury of the underlying tissue below the skin's surface that results from prolonged pressure) of the left lateral heel and an unstageable pressure ulcer of the right lateral ankle. This deficient practice was identified for 1 of 2 residents (Resident #172) reviewed for pressure ulcer management. This deficient practice was evidenced by the following: Refer to F 677 Reference: [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to maintain proper infection control practices during the a) Medication administration observation and b) Dining observation. This deficient practice was identified on 1 of 3 nursing units (Cherry Unit) and for 1 of 3 nurses (LPN #5) observed during the medication pass. This deficient practice was evidenced by the following: 1. On 12/01/23 at 8:16 AM, the surveyor observed Licensed Practical Nurse (LPN #5) as he prepared and administered medications on the Cherry Unit. LPN #5 first obtained a treatment cart from the other end of the hall and placed it beside the medication cart and stated that he intended to use it for additional work space. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to maintain dignity during mealtime for residents during dining observation. This deficient practice of not serving all residents seated at a table at the same time was observed for 2 of 3 meals in 1 of 2 dining rooms. The deficient practice was evidenced by the following: On 11/28/23 at 12:30 PM, in the second floor Hickory unit dining room, the surveyor observed residents preparing for meal service. Once meal trays arrived, at one table, staff served one resident who began eating and failed to serve the remaining residents at that table. At another table staff served two residents who began eating and failed to serve the remaining residents at that table. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to electronically transmit the discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, for 1 of 25 residents, (Resident #106) reviewed for resident assessments. The deficient practice was evidenced by the following: Review of Resident #106's discharge MDS assessment with initiation date 7/24/23 and completion date 8/2/23, indicated it was not transmitted. On 11/29/23 at 01:02 PM, the surveyor interviewed the MDS Coordinator who stated that the MDS assessment should have been transmitted within 14 days of completion. She further stated that they had remote MDS help at that time, and the transmission was missed. [...]

Inspectors wroteNJ00166442 Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner. This deficient practice was identified for 3 of 10 residents (Residents #175, # 104, #173) on 1 of 3 units (Cherry Unit) observed for incontinence care. This deficient practice was evidenced by the following: Refer to F725 and F686 On 12/05/23 at 9:10 AM, the surveyor interviewed Certified Nursing Assistant (CNA #5) who stated that she was assigned to 13 residents. CNA #5 stated that five of the residents on her assignment were dependent on staff for incontinence care. CNA #5 stated that one of the resident's who she had already changed had removed their brief and it was messy. [...]

Inspectors wroteNJ Complaint # NJ 1560250 Based on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to consistently provide effective pain relief allowing the resident to achieve optimal results during physical therapy sessions. This deficient practice was identified in 1 of 1 resident (Resident #222) reviewed for pain management and was evidenced by the following: On 12/04/23 at 11:11, AM, the surveyor reviewed the admission Record for Resident #222 which revealed the resident was admitted to the facility following hip replacement surgery for physical therapy and wound care. On 12/04/23 at 11:13 AM, the surveyor reviewed the physician orders which showed Resident #222 was prescribed the following medications for pain. [...]

Inspectors wroteNJ Complaint # NJ00163433 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to a.) provide nursing related services to assure residents maintain the highest practicable physical, mental, and psychosocial wellbeing as determined by resident assessments and individual plans of care in accordance with the facility assessment and b.) maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Refer to F677 Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. [...]

Inspectors wroteBased on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the Narcotic Shift Count logs were completed in accordance with facility policy and accurately account for and document the administration of controlled medications. This deficient practice was identified on 1 of 3 medication carts and was evidenced by the following: On 11/29/23 at 12:56 PM, the surveyor, in the presence of the Registered Nurse Supervisor (RNS), reviewed the narcotic logbook for the Cherry nursing unit's middle hall's medication cart. The logbook contained narcotic shift logs which revealed the following incomplete or blank sections: Going off Duty Nurse's Signatures missing for: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to a.) properly store medications and properly label opened multidose medications. This deficient practice was observed in 1 of 2 medication storage rooms and 3 of 3 medication carts reviewed for medication storage and labeling and was evidenced by the following: On 11/29/23 at 10:42 AM, the surveyor, in the presence of the Licensed Practical Nurse Unit Manager #2 (LPN/UM #2) reviewed the Hickory nursing unit's medication storage room. The surveyor observed an opened tuberculin purified protein (a medication used to test for tuberculosis) multidose vial with no opened date on the vial. The LPN/UM #2 acknowledged the vial and confirmed it should have been dated and initialed once opened. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/28/23 from 09:46 AM to 10:29 AM, the surveyor, accompanied by the facility Food Service Director (FSD), observed the following in the kitchen: Upon surveyor entrance into kitchen and during tour, the FSD was not wearing a beard guard. In the walk-in freezer, one box of riblets and one box of chicken tenders were open and the plastic bags inside the boxes were open, leaving the meat products open to air. On the shelves by the pot sink, a stack of stainless-steel pans (for use in the steam table) were noted with wet nesting. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to ensure the narcotic medication compartment locked securely. This deficient practice was identified for 1 of 2 medication carts (low cart 1 on the Hickory unit) that was reviewed as part of the Medication Storage Task and was evidenced by the following: On 9/1/21 at 11:20 AM, the surveyor and Licensed Practical Nurse (LPN #1) were at the low cart 1 and LPN #1 unlocked the medication cart using a key. At that time, LPN #1 opened the bottom drawer of the cart revealing a fixed, metal compartment with a keyhole lock on the lid. LPN #1 utilized the key to unlock the compartment and then pulled on the lid and the compartment opened. LPN #1 closed the lid, inserted, and turned the key again. [...]