Careone at East Brunswick

Inspectors wroteComplaint number: NJ00172039 Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure meals were served at a palatable on 1 of 2 units reviewed for food temperatures. The deficient practice was evidenced by the following: On 6/23/25 at 11:30 AM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the Food Service Director (FSD). At 11:59 AM, the surveyor and FSD observed the first food truck arrived on the Canterbury South 1st floor unit. The surveyor and FSD observed the first lunch tray being served at 12:00 PM, at that time a test tray of a regular diet and regular consistency was identified by the surveyor and FSD, this tray was removed from the food truck and placed in the dayroom by the FSD. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 6/22/25 at 9:18 AM, the surveyor in the presence of the chef supervisor (CS) toured the kitchen and found the following: 1. On the chef preparatory table, the surveyor observed the can opener with a blackish color sticky debris. The CS stated the can opener was just used but should always be free of debris. 2. On a four-shelf storage rack, the CS stated on the pots, pans and serving trays were dry and ready for service. The surveyor observed wet nesting on 3, 1/4 size serving trays. 3. In the walk-in freezer the surveyor observed the ventilation fans with blackish dust-like debris on covers. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to adhere to accepted standards of infection control practices for the ensure proper use of personal protective equipment (PPE) for 3 of 3 staff in accordance with the Centers for Disease Control and Prevention guidelines for infection control. This deficient practice was evidenced by the following: On 6/22/2025 at 9:03 AM, the surveyor entered the facility and observed the front desk receptionist wearing a surgical mask under their chin. The receptionist stated the building had an active Covid-19 outbreak, and all staff and visitors were required to wear a surgical mask when in the facility. On 6/22/2025 at 10:10 AM, during the tour of the Canterbury South 1st floor unit the surveyor observed a housekeeper (HK) wearing a surgical mask under their chin. [...]

Inspectors wroteRepeat Deficiency Complaint #NJ00174978, and NJ00176742 Based on observation, interview and record review, it was determined that the facility failed to; a) clarify physician's admitting medication orders for 1 of 2 residents admitted for Hospice services (Resident #81); b) ensure a resident received their medications as prescribed by their physician for 1 of 24 residents sampled (Resident #88), in accordance with professional standards of practice. This deficient practice was as follows: 1. On 6/23/25 at 9:03 AM, the surveyor reviewed the closed medical record of discharged Resident #81. A review of the Resident admission Record (an admission summary) reflected the resident was admitted for Hospice respite to the facility with diagnoses which included multiple sclerosis, heart failure, and chronic kidney disease. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan (CP) for a resident on long-term use of anticoagulant (type of medication that slows down the process of blood clotting) medication. This deficient practice was identified in 1 (one) of the 18 residents (Resident#18) reviewed for CP and was evidenced by the following: On 6/22/25 at 10:15 AM, the surveyor observed Resident #18 asleep in bed. On 6/22/25 at 1:00 PM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #18, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #18 was admitted with diagnoses that included but were not limited to atrial fibrillation (irregular heartbeat) and malignant neoplasm of the uterus (type of uterine cancer). [...]

Inspectors wroteComplaint #NJ00183311 Based on 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 abuse within two hours of being made aware of the allegation. The incident allegedly occurred on 11/23/24 when the Certified Nursing Assistant (CNA) allegedly inappropriately touched a resident during an initial skin evaluation (Resident #90). This deficient practice was identified for 1 of 3 investigations reviewed, and was evidenced by the following: On 6/24/25 at 9:49 AM, the surveyor reviewed the closed medical record for Resident #90 who was discharged from the facility. The surveyor reviewed the medical record for Resident #90. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow a Physician's Order for an Oxygen (O2) dependent resident in accordance with professional standards of practice for 1 (one) of 2 residents, (Resident #45), reviewed for respiratory care. 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 wroteComplaint #NJ00175069 Based on interviews, medical record reviews, and a review of other pertinent facility documentation, it was determined that the facility failed to revise the comprehensive care plan (CP) interventions for 1 (one) of 18 residents (Resident #83) reviewed for a comprehensive CP. This deficient practice was evidenced by the following: On 6/23/25 at 9:18 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #83, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #83 was admitted with diagnoses that included but were not limited to displaced bimalleolar (ankle) fracture of right lower leg, subsequent encounter for closed fracture with routine healing disease, and dementia (loss of memory). [...]

Inspectors wroteComplaint #NJ00175069 Based on the interview, record review, and review of pertinent facility documents, it was determined that the facility failed to: a.) consistently document an actual skin condition of the pressure ulcer (PU, damaged to the skin or underlying tissue) upon admission, b.) provide a necessary treatment and services consistent with professional standards of practice, to promote healing, and prevent worsening of a PU, c.) ensure pressure-relieving interventions according to the physician's order, and d.) consistently complete a weekly skin condition assessment. This deficient practice was identified in 1 (one) of 2 residents (Resident #83) reviewed for pressure ulcers/injuries. This deficient practice was evidenced by the following: On 6/23/25 at 9:18 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #83, which revealed the following: [...]

Inspectors wroteBased on record review, interview, review of facility grievances, and review of facility policy, the facility failed to implement their abuse policy when they did not identify an allegation of employee to resident abuse, failed to report the allegation in a timely manner, and failed to thoroughly investigate the allegation for one (Resident (R)48) of one residents reviewed for abuse allegations of 22 sampled residents.

Inspectors wroteBased on record review, interview, review of grievance files, and facility policy review, the facility failed to ensure that an allegation of employee to resident abuse was reported immediately (within two hours) to the state survey agency (SSA) for one (Resident (R)48) of one resident reviewed for abuse of 22 sampled residents.

Inspectors wroteBased on record review, interview, review of grievance files, and facility policy review, the facility failed to ensure that an allegation of staff to resident abuse was thoroughly investigated in a timely manner for one (Resident (R)48) of one resident reviewed for abuse of 22 sampled residents.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain appropriate kitchen sanitation practices and failed to store food in accordance with the professional standards for food service safety to prevent the development of food borne illness. This deficient practice was evidenced by the following: On 7/29/21 at 10:50 AM, the surveyor toured the kitchen along with Director of Culinary Services (DCS). During the tour, the surveyor observed the following: 1.) The high temperature dishwasher was observed with a temperature of 177 degrees Fahrenheit (F) during the rinse cycle. The surveyor instructed the DCS to run the dishwasher for a second rinse cycle which displayed a temperature of 176 degrees F. The DCS ran the dishwasher for a third rinse cycle that showed a temperature of 177 degrees F. [...]