Elizabeth Nursing and Rehab Center

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 9/15/24 at 9:35 AM, the surveyor in the presence of the Chef observed the following during the kitchen tour: 1. The inside of the ice machine was observed in two areas with a black colored substance. The Chef stated the maintenance department oversees cleaning the ice machine and they were not aware of the black colored substance in the ice machine. On 9/15/24 at 12:34 PM, the surveyor conducted an interview with the Maintenance Director (MD), who stated the ice machine was cleaned monthly, normally the middle of the month. The MD was unable to state what the substance was or how long it had been there. [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide a safe medical equipment (wheelchair with no armrest pad) which would provide additional support and comfort to protect the arm of a resident. This deficient practice was observed for one (1) of eighteen (18) residents (Resident #23) reviewed for assistant medical device. This deficient practice was evidenced by the following: On 9/15/24 at 11:38 AM, during initial tour, the surveyor observed Resident #23 who was seated in a high back wheelchair in the dayroom. The surveyor further observed the left-side armrest of the resident's high back wheelchair had no cushion. On 9/16/24 at 9:35 AM, the surveyor observed Resident #23 in the day room. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed (a). remove and dispose a discontinued medication (Namenda 5 mg) from the active inventory, this was identified for one (1) of four (4) residents, (Resident #85) observed during medication administration and (b). properly label, store, and dispose medications in two (2) of four (4) medication carts inspected. This deficient practice was evidenced by the following: a). On [DATE] at 9:05 AM, during morning medication pass observation, the surveyor observed a Licensed Practical Nurse (LPN# 1) preparing medications for Resident #85. LPN #1 opened the medication cart and pulled out a bingo card (a bubble pack which contained one dose of medication commonly used in long term care facilities) which contained Memantine (Namenda) 5mg tablets. [...]

Inspectors wroteBased on observation, interview, record review and review of facility provided documentation, it was determined that the facility failed to provide a comprehensive nutritional assessment to identify the nutritional needs of newly admitted and re-admitted residents to the facility within a 14 day period as required by Centers of Medicare & Medicaid Services (CMS). This deficient practice was identified for 4 of 9 newly admitted / re-admitted residents reviewed for nutritional assessments between 3/28/23 to 4/17/23, (Resident #231, 232, 233, and 234), and was evidenced by the following: The surveyor reviewed the Resident admission List supplied by the Admission's Director for residents admitted or re-admitted to the facility from 3/28/23 to 4/17/23 with the following

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) store, label, and date potentially hazardous foods to prevent food-borne illness On 5/3/23 at 9:30 AM, the surveyor entered the facility kitchen and asked to tour with the Food Service Director (FSD), but the FSD was not in the facility, the tour began with the available Chef Supervisor (CS). At this time, the surveyor and CS toured the kitchen and observed the following: 1. In the Refrigerator/Freezer combo located in the dry storage area, the surveyor observed in the refrigerator a 48-ounce container of Ricotta cheese with a written date of 4/24. The CS could not state if that date was the received, open, or discard date. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure a recommendation made by the Consultant Pharmacist was acted upon in a timely manner. This deficient practice was identified for 1 of 6 residents reviewed for medication management (Resident #6). The evidence was as follows: On 4/26/21 at approximately 10:00 AM, the surveyor interviewed the Licensed Practical Nurse (LPN) who stated that Resident #6 goes to the dialysis center three days a week due to end stage renal disease. On 4/27/21 at 9:42 AM, the surveyor observed Resident #6 sitting on the edge of the bed talking on the phone. The resident was unable to be interviewed at that time. The surveyor reviewed the medical record for Resident #6. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to: a.) report to the New Jersey Department of Health (NJDOH) an allegation of resident to resident abuse that occurred on 3/2/21 and b.) develop the facility's Abuse Prevention, Identification and Investigation policy in accordance with federal and state requirements for the timing of reporting such allegations of abuse to the state agency. The deficient practice was identified for 1 of 1 investigations of reportable incidents reviewed (which occurred between Resident #2 and #37) and was evidenced by the following: On 4/27/21 at 1:00 PM, the surveyor requested from the Director of Nursing (DON) any events that occurred in the past six months. The DON stated that the facility had no reportable incidents. [...]

Inspectors wroteBased on observation, interview and review of the medical record and review of other facility documentation, it was determined that the facility failed to adequately monitor the target behaviors for the use of psychotropic medications (mood altering medications) for 2 of 5 residents (Resident #2 and Resident #17) reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. On 4/27/21 at 9:03 AM, during initial tour of the first-floor nursing unit, the surveyor observed Resident #2 seated in the first-floor dining room with a breakfast tray on the table in front of the resident. [...]

Inspectors wroteBased on observation and interview on 4/26/21, it was determined that the facility failed comply with the minimum square footage requirements for private and semi-private resident bedrooms for 4 of 4 resident rooms (room [ROOM NUMBER], 230, 231, and 232). This deficient practice was evidenced by the following: During a tour of the building in the presence of the facility's Maintenance Director from 10:30 AM to 1:30 PM, the surveyor observed three 2-bedded resident bedrooms were less than 80 square feet per bed or 160 square feet total. This was noted for resident rooms 230, 231 and 232 which measured 14.5-ft. x 10-ft. for a total of 145 square feet. Also, one private room (single bed) was less than 100 square feet. Resident room [ROOM NUMBER] measured 9.5-ft. x 9-ft. for a total of 85.5 square feet.