Brighton Gardens of Edison

Inspectors wroteBased on observation, interviews, and review of facility documentation it was determined that the facility failed to a.) handle, clean and sanitize dishware in a manner to prevent microbial growth and cross contamination, and b.) wear hair restraints to maintain proper kitchen sanitation. This deficient practice was evidenced by the following: On 10/10/24 at 9:22 AM, the surveyor entered the kitchen with a second surveyor. The surveyors observed a staff member at the dish machine without a hair restraint. At 9:35 AM, the surveyors began the kitchen tour with the Dining Director. The surveyors observed the same staff member (now with a hair restraint worn) load the dish machine with soiled dishware and bare hands. He then removed clean bowls from the clean side of the dish machine without performing hand hygiene and glove application. [...]

Inspectors wroteBased on interview, record review and review of pertinent facility documents, it was determined that the facility failed to complete reference checks on employees before their start date. The deficient practice was identified for 5 of 6 employees reference checks reviewed under Sufficient and Competent Nurse Staffing task. The deficient practice was evidenced by the following: On 10/15//24, the surveyor reviewed six employee files of employees hired since the last standard survey which revealed that five of the six did not have reference checks done prior to the start of employment. RN #1, date of hire 12/4/23 LPN (Licensed Practical Nurse) #1, date of hire 9/5/23 LPN #2, date of hire 8/17/23 LPN #3, date of hire 1/30/24 Housekeeper#1, date of hire 11/20/23 On 10/15/24, the surveyor requested the reference checks on the above employees. [...]

Inspectors wroteBased on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to notify the resident and or resident representative in writing of the reason for transfer or discharge to the hospital for 2 of 2 residents (Resident #8 and Resident #173) reviewed for hospitalization. This deficient practice was evidenced by the following: 1.) On 10/11/24 at 9:52 AM, the surveyor observed Resident #8 out of bed in a high back wheelchair in the common area with activities. On 10/11/24, the surveyor reviewed the Electronic Medical Record (EMR) which indicated that Resident #8 was admitted to the facility for long term care. Further review showed there was a Discharge/Return Anticipated MDS completed on 5/16/24 following a transfer to the hospital for treatment of a sacral wound. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to obtain an admission weight for 1 of 3 residents, Resident # 173, reviewed for nutrition. This deficient practice was evidenced by the following: On 10/10/24 at 11:19 AM, during the initial tour, the surveyor observed Resident #173 in bed with their eyes closed. The resident's family member was at the bedside and stated the resident had just been readmitted to the facility. The surveyor reviewed the electronic medical record (EMR) for Resident #173. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; end stage renal disease (the kidneys can no longer function properly) and dependence on renal dialysis (a renal replacement therapy that removes waste and excess fluids from the blood). [...]

Inspectors wroteBased on observations, interviews, 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 performed on 10/11/24, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 27 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 7.41 %. This deficient practice was identified for two (2) of four (4) residents, (Resident #12 and #13), that were administered medications by one (1) of two (2) nurses (Licensed Practial Nurse (LPN #1). The deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on interviews, record review, and review of pertinent documents, it was determined that the facility failed to protect a resident (Resident #31) from verbal abuse by a Certified Nurse Aide (CNA #1) by failing to ensure: a.) the facility policy was followed to identify an allegation of abuse, b.) that upon receiving an allegation of abuse on 6/20/23 during the 7:00 AM to 3:00 PM shift, the facility immediately protected Resident #31, and other residents from potential abuse, and c.) a thorough investigation was immediately initiated. This deficient practice occurred for 1 of 3 residents reviewed for abuse. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to treat a resident in a dignified manner. This deficient practice was identified for 1 of 1 resident observed for pressure ulcer wound dressing change, Resident #14. On 6/19/23 at 12:27 PM, the surveyor observed Resident #14 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor further observed that the resident had a dressing to the right foot. On 6/21/23 at 9:35 AM, the surveyor observed the Licensed Practical Nurse (LPN) perform wound care to the right heel of Resident #14. At the conclusion of the wound care, the LPN taped the dressing and then proceeded to write her initials including the date 6/21/23, on the tape after it had been applied to the resident. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of staff-to-resident verbal abuse. This deficient practice was identified for 1 of 3 reportable investigations reviewed, involving Resident #31 and Resident #15. This deficient practice was evidenced by the following. On 6/22/23 at 11:30 AM, during Resident Council Interview Resident #15 informed the Surveyor that on 6/19/23 CNA #1 had dropped flowers in a vase belonging to Resident #15. Resident #15 explained to CNA #1 that the flowers had special meaning and that Resident #15 would like the flowers placed back into the vase. Resident #15 continued to explain that CNA #1 responded, Who cares they're dead anyway. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, the facility failed to implement their abuse policy to investigate an allegation of verbal abuse between a Certified Nursing Assistant (CNA #1) and resident. This deficient practice was identified for 1 of 3 resident's (Resident #31) reviewed for abuse. The deficient practice is evident by the following: On 6/22/23 at 11:30 AM, during Resident Council Interview Resident #15 informed the Surveyor on 6/19/23 that CNA #1 had dropped flowers in a vase belonging to Resident #15. Resident #15 explained to CNA #1 that the flowers had special meaning and that Resident #15 would like the flowers put back into the vase. As per Resident #15, CNA #1 responded, Who cares they're dead anyway. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately code resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for one 1 of 12 residents, (Resident #21) reviewed for accurate coding of MDS. This deficient practice was evidenced by the following: On 6/20/23 at 10:01 AM, Resident #21 was observed lying in bed awake, alert, and responded appropriately to the surveyor. The surveyor observed floor mats against the wall by the window in the resident's room. Resident #21 had their call bell within reach. On 6/21/23 at 9:43 AM, Resident #21 was observed lying in bed awake, alert, and verbally responsive. The resident informed the surveyor that they were ok. The resident had no complaints of pain or discomfort. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to carry out a comprehensive care plan (CP) for 1 of 12 residents reviewed for the fulfillment of a care plan, Resident #21. This deficient practice was evidenced by the following: On 6/20/23 at 10:01 AM, Resident #21 was observed lying in bed awake, alert, and verbally responsive. The surveyor observed floor mats that were leaning against the wall by the window. On 6/21/23 at 9:43 AM, Resident #21 was observed lying in bed awake, alert, and verbally responsive. The surveyor observed floor mats that were leaning against the wall by the window. The surveyor reviewed the resident's hybrid (paper and electronic) medical chart which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise a comprehensive care plan for 2 of 18 residents reviewed, Resident #14 and Resident #21. This deficient practice was identified by the following: On 6/19/23 at 12:27 PM, the surveyor observed Resident #14 in the room seated in their wheelchair. The resident was alert and verbally responsive. The surveyor further observed that the resident had a surgical dressing to their right foot. The surveyor reviewed Resident #14's hybrid medical records. The admission Record reflected that Resident #14 was admitted . to the facility with medical diagnoses which included but were not limited to Atrial Fibrillation, Type 2 Diabetes Mellitus, Anemia, and Hypertension. [...]

Inspectors wrote1) Based on observation, interviews, and record review, it was determined the facility failed to consistently follow standards of clinical practice with regard to a.) accurately documenting medication administration, and b.) correctly following physician's orders for 2 of 12 residents, Resident #19 and Resident #15. The deficient practice is 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 record review, it was determined that the facility failed to ensure that medications were 1. stored in a secure locked environment, 2. expired medications were removed from a resident's active inventory after it had expired and/or been discontinued by the physician in accordance with professional standards of clinical practice, 3. removed expired narcotics kept in a locked backup box. This deficient practice was identified for 1 of 1 units reviewed during the facility unit inspection process. This deficient practice was evidence by the following: 1. On 6/19/23 at 10:03 AM, a surveyor along with another surveyor requested from the Unit Clerk (UC), if someone could open the medication room door for inspection. At that time the UC volunteered to open the locked medication room door, and had access to the passcode. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the Consultant Pharmacist (CP) failed to identify and notify the facility of medication irregularities. These irregularities were identified for 2 of 12 residents reviewed, Resident #19, and Resident #21. The deficient practice was evidenced by the following: 1. The surveyor reviewed the hybrid medical records of Resident #19 which revealed the following: The resident's admission Record listed diagnoses that included but were not limited to Alzheimer's Disease [a progressive disease that destroys memory and other important mental functions], Hypertension, and Hyperlipidemia. The Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 4/3/23, indicated that the facility assessed the resident's cognitive status using a Brief Interview for Mental Status (BIMS). [...]

Inspectors wroteBased on observation, interviews, and review of facility policies, it was determined the facility failed to properly label and date potentially hazardous foods in a safe and sanitary environment to prevent the development of food borne illness. This deficient practice was evidenced by the following. On 6/19/23 from 09:45 AM through 10:30 AM, the surveyor completed the initial kitchen tour located in the Assisted Living (AL) section of the building with the Food Service Director (FSD) and observed the following: 1. On top of the Sandwich/Deli counter prep area, the surveyor observed multiple opened bags of assorted loaves of bread with received dates but no open and/or use-by dates: a. One loaf of Rye bread, with a received date of 6/16/23 b. One loaf of Wheat bread, with a received date of 6/16/23 c. One loaf of [NAME] bread, with a received date of 6/16/23 d. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain proper infection control practices, which was identified during 1 of 1 wound treatment observation for Resident # 14. This deficient practice was evidenced by the following: On 6/19/23 at 12:27 PM, the surveyor observed Resident #14 in their room seated in a wheelchair. The resident was alert and verbally responsive. The surveyor further observed that the resident had a dressing on the right foot. The surveyor reviewed Resident #14's medical record on 6/1/23 at 12:29 PM. The admission Record reflected that Resident #14 was admitted to the facility with medical diagnoses, which included but not limited to Atrial Fibrillation, Type 2 Diabetes Mellitus, Anemia, and Hypertension. [...]