Echelon Care & Rehab

Inspectors wroteBased on observation and interview on 6/18/25 in the presence of the Maintenance Director (MD) and Regional Plant Operations Director (RPOD), it was determined that the facility failed to maintain their Packaged Terminal Air Conditioner (PTAC) units in safe operating condition. This deficient practice was evidenced for 52 of 67 PTAC units observed by the following: Observations while touring the facility from 9:00 AM to 1:00 PM, revealed that PTAC filters were missing, clogged and dirty, bent frames and filters laying on the floor not properly installed. In an interview the MD and the RPOD both confirmed the findings. A policy and procedure and PTAC maintenance log was requested but not provided at the time of the LSC exit conference. The Administrator was notified of the deficient practice at the Life Safety Code exit conference on 6/19/25 at 1:30 PM. NJAC 8:39 - 31.2(e)

Inspectors wroteBased on observation, interview, and review of facility provided documents, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents. This deficient practice was identified for 4 of 4 observed resident pantry rooms (200 Unit, 300 Unit, 400 unit and 500 Unit) as evidence by the following: On 6/18/25 at 12:26 PM, the surveyor toured the 200-Unit pantry room in the presence of the Regional Director of Nursing (RDON and observed the Packaged Terminal Air Conditioner (PTAC) unit had rust on the outside and black colored debris and yellow debris located inside the uncovered area. The RDON stated that housekeeping was responsible to clean the pantries including the PTAC. At that time, the Maintenance Director observed the PTAC and stated that the PTAC did not work but should still be clean. [...]

Inspectors wroteBased on observation and interview from 6/18/25 in the presence of the Maintenance Director (MD) and the Regional Plant Operations Director (RPOD), it was determined that the facility failed to ensure that wooden handrails were installed, secured and splinter free in all required locations. This deficient practice was identified for 3 of 6 areas observed, had the potential to affect all residents, and was evidenced by the following by the following: 1). An observation at 12:22 PM revealed that the handrail by resident rooms [ROOM NUMBERS] had sharp edges due to a missing edge guard. 2). An observation at 12:40 PM revealed that the smoking courtyard exit/egress wooden ramp had a handrail that was unfinished and dry. The wooden ramp handrail was observed to have splinters along the entire length, approximately 30-feet. 3). [...]

Inspectors wroteComplaint NJ #: 177921 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain the resident's environment, and living areas in a safe, sanitary, and homelike manner by ensuring that damaged flooring, chair rail, and wall board were identified and repaired in a timely manner. This deficient was identified for 2 of 4 nursing units (200 Unit and 500 Unit) and was evidenced by the following: 1. On 6/19/25 at 10:45 AM, the surveyor observed that the tile flooring in room [ROOM NUMBER] had multiple areas that were buckled, cracked, and chipped and there was blue painter's tape placed over several of the affected areas. There were no residents present in the room at the time. [...]

Inspectors wroteBased on observation, interview, review of medical records and other facility documents, it was determined that the facility failed to complete a Significant Change in Status Assessment (SCSA) using the Resident Assessment Instrument (RAI) process on a resident who elected hospice benefits. This deficient practice was identified for 1 of 1 resident (Resident #118) reviewed for hospice service. This deficient practice was evidenced by the following: According to the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, updated October 2024 showed: An SCSA must be completed within 14 days of determining a significant change from baseline. The resident's condition is not expected to return to baseline within two weeks. Comparison with the most recent comprehensive and quarterly assessments is crucial. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss mattress was accurately set according to the resident's weight and the resident's feet were elevated off of the bed bilaterally with a pillow in accordance with a physician's order for a resident who was previously identified to have had an alteration in skin integrity. This deficient practice was identified for 1 of 2 residents (Resident #192) reviewed for pressure ulcers and was evidenced by the following: On 6/17/25 at 10:55 AM, the surveyor observed Resident #192 lying in bed awake. The resident's bedding covered the foot of the bed where there appeared to have been an outline of an air mattress pump that was covered by the resident's bedding. [...]

Inspectors wroteC #: NJ00170177 Based on interviews, medical record review, and review of other pertinent facility documents on 2/5/2024, it was determined that the facility failed to: document according to the facility policy when the resident's Responsible Representative (RR) was notified of a change in the resident's medication regimen for 1 of 3 residents reviewed (Resident #2) and consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status, and care provided to the resident according to facility policy and protocol for 2 of 3 residents (Resident #2 and #3) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the facility admission Record (AR), Resident #2 was admitted with diagnoses that included but were not limited to: [...]

Inspectors wroteBased on observation, interview, and pertinent record review, it was determined that the facility failed to ensure: a) accountability of the Narcotic Shift Count logs were completed in accordance with facility policy and accurately accounted for and documented the administration of controlled medications and b) medications were administered in accordance with the medication's cautionary statement and manufacturer specifications. This deficient practice was identified on 5 of 5 medication carts observed on 4 of 4 nursing units and for 2 of 3 nurses who administered medications to 2 of 6 residents (Resident #95 and Resident #179) observed during the medication observation pass. This deficient practice was evidenced by the following: 1. [...]

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 4 of 4 medication carts and 1 of 2 medication storage rooms reviewed for medication storage and labeling and was evidenced by the following: On [DATE] at 9:58 AM, the surveyor, in the presence of the Licensed Practical Nurse #1 (LPN #1) reviewed the fifth floor's east side medication cart. The surveyor observed one opened 10 milliliter (ml) bottle of Refresh gel eye drops, and one opened 15 ml bottle of GenTeal Tears eye drops stored in the space as opened containers of over the counter (otc) medications. [...]

Inspectors wroteComplaint #NJ00156539 and NJ00156915 Based on observation, interviews, and review of pertinent facility documentation it was determined that the facility failed to serve hot foods at an acceptable temperature for the residents. This deficient practice was identified in the kitchen tray line during the plating of the lunch meal service for the 4th floor high side. The deficient practice was evidenced by the following: On 12/19/23 at 12:22 PM, the surveyor met with the Food Services Director (FSD) to obtain food temperatures on the kitchen tray line. The FSD obtained a thermometer and stated that it was the thermometer that was used to check the lunch meal. The FSD and surveyor approached the cook area where steam was observed coming from the steam table. The FSD tested the temperature of spaghetti which read 85 degrees Fahrenheit (F). [...]

Inspectors wroteComplaint #NJ00156539 Based on observations, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) failed to maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 12/12/23 from 10:19 AM-11:47 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. A dietary aide (DA#1) was sorting silverware and placing them into clear plastic bags that contained a napkin. He stated that he was bagging clean silverware for the meal trays. [...]

Inspectors wroteBased on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to maintain proper infection control practices during the Medication Administration Observation. This deficient practice was identified on 1 of 4 nursing units (Second Floor East/West) and for 2 of 3 nurses observed during the medication pass. This deficient practice was evidenced by the following: On 12/18/23 at 8:03 AM, the surveyor observed Licensed Practical Nurse (LPN #1) who was assigned to the 2 East Medication Cart as she prepared medications and administered them to Resident #95. When finished, LPN #1 failed to perform hand hygiene before she returned to the medication cart and charted the medications as administered. At 8:09 AM, LPN #1 obtained the automated blood pressure machine and entered the room of Resident #31. [...]

Inspectors wroteComplaint NJ #:159091 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to notify the resident's representative of a change in condition for 1 of 35 residents (Resident #431) reviewed. This deficient practice was evidence by the following: According to the admission Record, Resident #431 was admitted to the facility with diagnoses which included, adult failure to thrive, dementia, and personal history of covid-19. A review of the individualized Care Plan (CP) created 12/9/21, reflected a focus area: the resident's family had established an advanced directive (to appoint a person other than yourself to make health care decisions for you) with an intervention to inform resident/representative of any changes in status or care needs. A review of the Progress Note (PN) reflected the following: [...]

Inspectors wroteComplaint #: NJ00159091 Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment by: a) ensuring that resident's clothing was laundered and returned in a timely manner and b) ensuring that repairs were made to damaged walls and moldings in a timely manner. This deficient practice was observed for 1 of 2 residents (Resident #69) observed for personal property and for 1 of 4 nursing units (Second Floor/East). This deficient practice was evidenced by the following: a. On 12/12/23 at 12:32 AM, during the initial tour of the facility the surveyor observed Resident #69 seated on the side of the bed. The resident stated that his/her clothing was missing and he/she was only able to be changed into clean clothing once in the past three days. [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS) for 4 of 29 residents reviewed (Residents #23, #428, #132 and #19). This deficient practice was evidenced by the following: 1. The surveyor reviewed the admission Record for Resident #23 which reflected that the resident was admitted with diagnoses that included pancreatitis (an inflammation of the pancreas). The surveyor reviewed the Weights and Vitals Summary which reflected a weight of 142 pounds on 11/21/23 which was corrected on 11/27/23 to reflect a weight of 127.2 pounds. The surveyor reviewed Resident #23's admission MDS, an assessment tool utilized to facilitate the management of care, dated 11/27/23 and reflected a weight of 146 pounds. [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documents, it was determined that the facility failed to consistently follow appropriate professional standards of practice for: a) medication administration and b) accurately completing the Psychotropic Monthly Summary for 1 of 5 residents (Resident # 84) reviewed for unnecessary medications, psychotropic medications, and medication regime review for 1 of 3 nurses on 1 of 2 nursing units (2 East) reviewed for the medication administration observation. 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 facility documentation it was determined the facility failed to ensure that physician orders were obtained to change a resident's inner cannula of a tracheostomy (opening surgically created through the neck into the windpipe and inserting a tube to allow air to fill the lungs). This deficient practice was identified in 1 of 1 resident reviewed for tracheostomy care (Resident #433) and was evidenced by the following: On 12/12/23 at 01:06 PM, during the initial tour of the facility the resident was observed sitting at the bedside. The resident had a tracheostomy and oxygen was being provided with a trach collar (a device to deliver humidified oxygen to a tracheostomy). During the observation the resident was with the speech therapist and discussed swallow evaluations and the possibility of diet advancement following the swallow evaluation. [...]

Inspectors wrote2. On 12/12/23 at 10:56 AM, during the initial tour of facility the surveyor observed Resident #132 lying in bed. The resident stated that all was well except for pain and the resident lifted his/her shirt to show a colostomy bag (an opening on the abdomen for bowel discharge). The surveyor reviewed Resident #132's admission Record (an admission summary) which showed that the resident was admitted to the facility with diagnoses that included but not limited to: colostomy, parastomal hernia (part of the bowel pushed through the abdominal muscle around the colostomy opening) and irritable bowel syndrome. A review of the MDS dated [DATE] revealed that Resident #132 had a Brief Interview of Mental Status (BIMS) score of 11 out of 15, which meant the resident had mild cognitive impairment. Review of Section J, titled Health Conditions revealed the resident had a pain assessment completed. [...]

Inspectors wroteBased on observation, interviews and review of facility documentation it was determined that the facility failed to a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses, b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination and c.) failed to maintain adequate infection control practices during food service in the kitchen. This deficient practice was observed and evidenced by the following: On 01/24/22 from 09:54 AM -11:55 AM, the surveyor toured the kitchen in the presence of the Food Service Director (FSD) and observed the following: 1. The foot pedal trash can at handwashing sink #1 was not lined with a trash bag and both trash and debris were observed in the can. [...]

Inspectors wroteBased on observation, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure that an updated advance directive was accurately maintained within a resident's medical record, in accordance with the facility policy. This deficient practice was identified for 1 of 2 residents (Resident #48) reviewed for Advance Directives and was evidenced by the following: During the initial tour of the facility on [DATE] at 10:32 AM, the surveyor observed Resident #48 seated in a reclining wheelchair at the bedside. The resident was non-verbal and did not maintain eye contact when spoken to. Review of Resident #48's admission Record that was printed on [DATE] at 09:56 AM, revealed that the resident was readmitted to the facility in November of 2021 with diagnoses which included but were not limited to: [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to administer a medication in accordance with a physician's orders and consistent with professional standards. This deficient practice was identified for 1 of 5 residents (Resident #108) reviewed for medications and 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, interviews, and review of pertinent facility documentation it was determined that the facility failed to serve hot and cold foods at an acceptable temperature for the residents. This deficient practice was identified for 5 of 5 residents who attended a Resident Council group meeting, and on 1 of 4 nursing units during the lunch meal service and was evidenced by the following: During the initial tour of the 4th floor unit on 01/24/22 at 10:42 AM, Surveyor #1 interviewed Resident # 95 who stated that the food could be warmer. Resident #95 stated that when he/she eats in their room the breakfast meal is not hot. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/9/21, revealed Resident #95 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that the resident was cognitively intact. [...]

Inspectors wroteBased on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure infection control practices were implemented in accordance with facility policy and accepted national standards to prevent the possible spread of infection by failing to: a) properly don (put on) and doff (take off) personal protective equipment (PPE) and b) perform hand hygiene after glove removal for 1 of 3 residents reviewed for transmission-based precautions (Resident #132) and c) ensure respiratory equipment was kept in a clean and sanitary condition, and stored properly for 1 of 2 residents reviewed for respiratory equipment (Resident #692). This deficient practice was evidenced by the following: 1. [...]