Complete Care at Arbors

Inspectors wroteBased on observation, interview, and review of medical records, it was determined that the facility failed to provide necessary treatment services, consistent with professional standards of clinical practice by not a.) securing medications during medication administration observation for 1 of 3 nurses; b.) notifying a physician regarding a resident's refusal of medication for 1 of 1 residents (Resident #31); c.) applying skin protective devices as ordered by a physician for 1 of 2 residents (Resident #8) reviewed for pressure ulcers; and d.) destroying unused medication properly during medication observation for 1 of 3 nurses. Reference: New Jersey Statutes, Title 45, Chapter 11, Nursing Board, The Nurse Practice Act for the state of New Jersey states; [...]

Inspectors wroteComplaint # NJ175184, NJ176084, NJ179637 Based on observations, interviews, and review of pertinent facility documents, the facility failed to ensure residents who required assistance with their daily activities of living (ADLs) a.) received incontinence care and b.) staff answered resident call systems to provide care and services. This deficient practice was identified for 1 of 4 residents reviewed for bowel and bladder (Resident #65); 2 of 8 residents observed during incontinence rounds (Resident # 29 and Resident #63); and on 1 of 2 nursing units (Rosewood). The evidence was as follows: 1. On 3/23/25 at 10:10 AM, the surveyor interviewed the Licensed Practical Nurse/Unit Manager (LPN/UM #1), who stated the unit today had five certified Nurse Aides (CNA) for 48 residents. [...]

Inspectors wroteBased on observations, interviews, record review and other pertinent facility documentation it was determined that the facility failed to use appropriate infection control practices to prevent the spread or reduce the risk of infection by ensuring a.) proper use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP) for 2 of 2 residents reviewed for EBP (Resident #81 and #397), b.) label and date piston syringe irrigation kit (a device intended for medical purposes that consists of a calibrated hollow barrel and a movable plunger) in a manner to prevent contamination for infection control identified for 1 of 1 resident reviewed for tube feeding (Resident #64), and c.) respiratory device tubing and mouthpiece/ mask were stored in protective covering identified for 1 of 2 residents (Resident #17) reviewed for respiratory care. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) maintain infection control to reduce the risk of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice during a wound care treatment and b.) ensure a treatment was administered in accordance with a physician order. This deficient practice was identified for 1 of 3 residents reviewed for pressure ulcer (Resident #46), and was evidenced by the following: Reference: CDC Recommendations for Hand Hygiene, updated 2/27/24, Hand hygiene should be performed immediately before touching a patient; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; [...]

Inspectors wroteBased on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure dialysis communication forms between the facility and the contracted dialysis facility were consistently completed. This deficient practice was identified for 2 of 2 residents reviewed for dialysis (Resident #25 and Resident #45), and was evidenced by the following: 1. On 3/23/25 at 10:32 AM, during initial tour of the facility, the surveyor observed Resident #45 seated in their wheelchair in the hallway. Resident #45 stated that they go to dialysis three times a week. On 3/24/25 at 12:52 PM, the surveyor reviewed the medical record for Resident #45. A review of the Transfer/Discharge Report face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and review of pertinent records, it was determined that the facility failed to a.) ensure the accountability of the narcotic shift count logs were completed and b.) accurately account for and document the administration of controlled medications. This deficient practice was identified on 2 of 3 medication carts (Rosewood #1 and #4) reviewed and was evidenced by the following: On 3/25/25 at 10:20 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN), reviewed the Rosewood nursing unit's medication cart #1. The following was observed when the narcotic logbook was reviewed: The nurse's signature for the going off duty was missing on: 3/8/25 the 3:00 PM to 11:00 PM (evening) shift; 3/13/25 the 7:00 AM to 3:00 PM (day) shift; and 3/19/25 the evening shift. The nurse's signature for the coming on duty was missing on the 3/8/25 night shift. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined that the facility failed to properly store and secure medications. This deficient practice was observed in 1 of 3 medication carts reviewed (Rosewood #4), and was evidenced as follows: On 3/25/25 at 11:35 AM, the surveyor observed the Rosewood nursing unit's medication cart #4. The medication cart was next to the nurse's station and was unattended by any nursing staff. The cart was observed to be unlocked and had a bottle of acidophilus with pectin (a probiotic medication used to treat diarrhea) left unattended on top of the cart. At that time, the surveyor requested that the nurse assigned to the cart to be paged to come to the cart. The Registered Nurse (RN) assigned to the cart came out of a resident's room down the hall and approached the surveyor at the cart. [...]

Inspectors wroteBased on observation, interview, and review of pertinent 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 3/23/25 at 9:23 AM, during initial tour of the kitchen, the surveyor accompanied by the Head Chef, and observed the following: An opened container of bulk beef base. The beef base was not labeled with a use by date and contained a coffee mug that was used as a scooper in the beef base. A large, opened container of flour that contained a coffee mug left inside the flour to be used as a scooper. On 3/23/25 at 10:05 AM, the surveyor interviewed the Assistant Food Service Director (AFSD), who stated that the bulk beef base should have had a use by date on the container and the coffee mugs should not be used as scoopers. [...]

Inspectors wroteBased on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to ensure that the infection control practices for residents on transmission-based precautions (TBP) were followed to prevent the potential spread of infection by not utilizing contact precautions in accordance with facility policy and accepted national standards for 1 (one) of 2 (two) resident (Resident #79) reviewed for TBP and was evidenced by the following: According to the admission Record, Resident #79 was admitted to the facility with the diagnoses that included but was not limited to C-diff (infection of the large intestine (colon) caused by the bacteria Clostridium difficile) and MRSA (methicillin-resistant Staphylococcus aureus, a type of bacteria that is resistant to several antibiotics). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) develop and implement a baseline person-centered care plan to meet a resident's medical needs and b.) implement a focus and interventions that are specific to the resident's respiratory needs for 1 of 1 (Resident #148) investigated for respiratory care. The deficient practice was evidenced by the following: On 05/01/24 at 11:02 AM, during the initial tour, the surveyor observed Resident #148 lying in bed asleep receiving oxygen (O2) at two (2) liters per minute (lpm) via nasal cannula. On 05/02/24 at 11:03 AM, the surveyor observed Resident #148 lying in bed awake receiving oxygen at 2 lpm via nasal cannula. At that time, the surveyor interviewed the resident who stated that she received oxygen most the time. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to follow professional standards of clinical practice with respect to a.) obtaining a physician's order for the application of a treatment device utilized to manage a resident's edema, and b.) update the care plan to reflect a device utilized to manage edema for 1 of 22 residents reviewed (Resident #64). 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 wroteComplaint #: NJ 166493 Based on interview, record review, and review of facility documents, it was determined that the facility failed to thoroughly investigate a facility acquired pressure ulcer for 1 of 3 residents (Resident #146) reviewed for pressure ulcers. This deficient practice was evidenced by the following: The surveyor reviewed the closed record for Resident #146. According to the admission Record, Resident #146 was admitted with diagnoses which included, but were not limited to, COVID-19, major depressive disorder, severe protein-calorie malnutrition, and unspecified dementia. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/02/23, included the resident had a Brief Interview for Mental Status score of 06, which indicated the resident's cognition was severely impaired. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order for oxygen therapy. This deficient practice was identified for 1 of 1 resident (Resident #148) reviewed for respiratory care. This deficient practice was evidenced by the following: On 05/01/24 at 11:02 AM, during the initial tour the surveyor observed Resident #148 lying in bed sleeping receiving oxygen (O2) at two (2) liters per minute (lpm) via nasal cannula. On 05/02/24 at 11:03 AM, the surveyor observed Resident #148 lying in bed awake receiving oxygen at 2 lpm via nasal cannula. At that time, the surveyor interviewed the resident who stated that she received oxygen most the time. The surveyor reviewed the medical record for Resident #148. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to label, date, and store potentially hazardous foods appropriately to prevent food borne illness. This deficient practice was evidenced by the following: On 05/01/24 at 10:24 AM, the surveyor in the presence of the Food Service Director (FSD), toured the kitchen and observed the following in the dry storage pantry: 1. Two (2) packs of 12 bread that was identified as hamburger buns, had a used by date of 4/25/24. 2. A bag of [NAME] couscous toasted pasta was opened and not dated. 3. A bag of instant nonfat dry milk was opened with a used by date of 4/27/24. On 05/08/24 at 11:08 AM, the surveyor interviewed the FSD who stated that everything should have an opened date, used by date, and received by date on it. [...]

Inspectors wroteComplaint #: NJ 166943 Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to accurately document in the medical records for 3 of 26 residents (Resident #146, #147, and #245) medical records reviewed. This deficient practice was evidenced by the following: 1.) The surveyor reviewed the closed record for Resident #146. According to the admission Record, Resident #146 was admitted with diagnoses which included, but were not limited to, COVID-19, major depressive disorder, severe protein-calorie malnutrition, and unspecified dementia. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/02/23, included the resident had a Brief Interview for Mental Status score of 06, which indicated the resident's cognition was severely impaired. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to make survey results readily accessible to residents and visitors. This deficient practice was evidenced by the following: On 05/02/2024 from 11:02 AM to 11:37 AM, the surveyor conducted the resident council task with five (5) long-term care residents, who regularly attend resident council meetings. When asked if the residents were made aware of the location of the most recent survey results, 4 out of 5 residents (Resident #28, #55, #62, and #79) responded that they were not aware of where the most recent survey results were located. The surveyor reviewed the April 17th, 2024, resident council meeting minutes. Under standards to be discussed at each meeting, standard #5 revealed: The location of the State Survey Book is in the reception area. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure equipment was in good repair by A.) providing fall mats (safety mats that are placed on the floor along the side of the bed) that had rips along the seams exposing the foam interior and B.) failed to ensure medication carts and Emergency carts were free of dust and debris on the wheels and shelves. The deficient practice was identified for 2 out of 7 residents (Residents #63 and #73), 3 medication carts, and 2 emergency carts reviewed for the Environmental Task. The deficient practice was evidenced by the following: On 4/20/22 at 10:09 AM during the initial tour of the facility, surveyor #1 observed Resident #63 in bed. At this time, the surveyor observed a fall mat next to Resident #63's bed. The fall mat had a rip along the seam exposing the foam interior. [...]

Inspectors wroteBased on observation, interview and review of other facility documentation, it was determined that the facility failed to ensure the the call bell was within reach of the residents. The deficient practice was identified for 4 of 7 residents (Residents #63, Resident #28, Resident #11, and Resident #70) reviewed for the Environmental Task. The deficient practice was evidenced by the following: On 4/20/22 at 10:08 AM during the initial tour, surveyor #1 observed Resident #63 lying in bed. At that time, the surveyor observed the call bell on the ground behind the bed headboard out of reach from the resident. On 4/20/22 at 10:37 AM during the initial tour, surveyor #1 observed Resident #28 lying in bed. At that time the surveyor observed the call bell behind the bed headboard out of reach from the resident. On the same date and time, surveyor #1 observed Resident #11 lying in bed. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to maintain professional standards of nursing practice by not following a physician's order for 1 of 19 sampled residents, (Resident #52). 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 casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure that it was free of a medication error rate of five percent or greater by failing to ensure three medications were given within sixty minutes before or after the scheduled administration time. The deficient practice was observed for 1 of 7 residents (Resident #5) during the Medication Administration Task. The deficient practice was evidenced by the following: On 4/25/22 at 9:34 AM on the Rosewood Unit, the surveyor observed Licensed Practical Nurse (LPN) #1 prepare Resident #5's medication for administration. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 4/25/2022, at 3:15 PM, the Surveyor observed the following in the Rosewood Nourishment Room: 1. On the refrigerator door, located on the bottom shelf, one opened 24 ounce (oz) jar of kosher pickles was observed with resident's name and room number identified on lid. No use by date observed. Located on the same shelf, one opened 8 oz jar of sliced olives with resident's name and room number. No use by date observed. Throughout the bottom of the shelf, dried liquid was observed. 2. [...]

Inspectors wroteBased on observation, interview, record review and other pertinent facility documents, it was determined that the facility failed to ensure that A.) staff implemented appropriate hand hygiene after direct patient care by not performing hand hygiene for a minimum of 20 seconds, B.) failed to ensure medical waste was properly disposed of by staff leaving a used surgical drain on a resident's (Resident #426) bedside table and C.) failed to ensure a urinary drainage leg bag was properly cleaned for reuse according to the manufacturer's instructions. The deficient practice was identified for two residents (Resident #374 and Resident #426) during the Medication Administration Task and 1 of 2 residents (Resident #46) investigated for Catheters. The deficient practice was evidenced by the following: [...]