Inglemoor Rehabilitation and Care Center

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure 2 of 23 residents (Residents #14, #39) call bells were within reach and able to use to accommodate the residents' needs. This deficient practice was evidenced by the following: 1. On 6/16/25 at 10:20 AM, While conducting the initial tour of the facility, the surveyor observed Resident #39 in their room, sleeping in bed, with the call bell hanging, on the floor, and not within the reach if of the resident. The surveyor reviewed the electronic medical record (eMR) of Resident #39, and revealed the following: A review of the admission Record (AR; [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to issue the required beneficiary notice for 1 of 2 residents reviewed for Beneficiary Protection Notification, (Resident #141). This deficient practice was evidenced by the following: On 6/23/25 at 8:49 AM, the surveyor reviewed the Skilled Nursing Facility (SNF) Beneficiary Protection Notification (SNFBPN) Review completed by the facility for Resident #141 as followed: -The SNFBPN Review indicated Resident #141 last covered Medicare A day was 2/21/25, and Resident #141 remained in the facility. The SNFBPN Review further revealed that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) form was not given to Resident #141. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure licensed staff credentials were verified upon hire for 1 of 6 newly hired licensed staff reviewed, Staff Member #1, in accordance to facility's policy. The deficient practice was evidenced by the following: On 6/17/25 at 9:40 AM, the surveyor requested ten randomly selected newly hired employee files from the Director of Nursing (DON). On 6/17/25 at 1:18 PM, after a brief review of the facility provided files which did not contain any documented license verification, the surveyor asked the DON to provide the surveyor the initial license verification documentation for each of the newly hired employees. A review of the facility provided documented license verification for six of the new licensed employees revealed the following: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately reflect the resident status in the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care in accordance with the federal guidelines for 1 of 23 residents (Resident #75) reviewed for the accuracy of MDS coding. This deficient practice was evidenced by the following: A review of the Centers for Medicare & Medicaid Services (CMS's) Resident Assessment Instrument (RAI; helps facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan) Version 3.0 Manual, October 2024, reflected in SECTION I: ACTIVE DIAGNOSES . Intent: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to develop a baseline care plan for a newly admitted resident who received a psychotropic medication (med), specifically an antipsychotic med for 1 of 5 residents reviewed for unnecessary medications (Resident #191). This deficient practice was evidenced by the following: A review of Resident #191's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen, according to the standard of clinical practice specifically the posting of cautionary and safety signs indicating the use of oxygen were utilized for residents that received oxygen therapy for 1 of 1 residents reviewed for respiratory care (Resident #34). This deficient practice was evidenced by the following: Reference: National Institutes of Health defines oxygen (O2) as a colorless, odorless and tasteless gas. It will support life. It is noncombustible, but will actively support the burning of combustible materials. Some materials that will not burn in air will burn in O2. Materials that burn in air will burn more vigorously in O2. On 6/17/25 at 10: [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate and appropriate administration of a medication (med) for 1 of 6 residents observed during the facility's med pass observation. 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 wroteBased on interview and record review, it was determined that the facility failed to a.) ensure practitioners and providers documented appropriate indications for use of antipsychotic and antidepressant medications (meds) and b.) identified discrepancy between practitioners and providers documented diagnosis for use of antipsychotic medication in accordance with the professional standards of clinical practice and facility policy. This deficient practice was identified in 1 of 5 residents, Resident #75, reviewed for unnecessary meds. 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: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication per manufacturer specifications and standards of practice. This deficient practice was identified in 1 of 5 medication carts (med carts) observed in the facility. 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 wroteBased on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete and accurate medical records. This deficient practice was identified for 4 of the 23 residents reviewed (Residents #75, #79, #191, and #192). This deficient practice was evidenced by the following:1. During the initial tour of the Reflections unit on 6/16/25 at 10:30 AM, Surveyor #1 (S#1) observed Resident #79 seated in a wheelchair (w/c) and informed S#1 that they had multiple hospitalizations. S#1 reviewed the medical records of Resident #79, and revealed the following:A review of the admission Record (AR; an admission summary) revealed that Resident #79 was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 1 of 6 staff (Certified Nursing Aide) and b.) ensure laundry area maintained clean and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for 2 of 5 Certified Nurse Aides (CNAs) reviewed for mandatory education (CNA #1 and #2). This deficient practice was evidenced by the following: On 6/16/25 at 1:03 PM, the surveyor requested from the Director of Nursing (DON) the annual education that was done for 5 randomly selected CNAs based on their date of hire (doh). A review of the facility provided annual education transcripts included the following: CNA #1, with a doh of 3/11/16, did not have QAPI training. CNA #2, with a doh of 4/29/24, did not have QAPI training. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to properly label, store and dispose of medications in 2 of 9 medication carts inspected. This deficient practice was evidenced by the following: On 8/4/21 at 9:15 AM, the surveyor inspected the Heritage [NAME] medication cart #2 in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened Novolog Insulin that did not contained a label with a resident's name. At that time, the surveyor interviewed LPN #1 who stated that the Novolog insulin pen should have contained a label with the resident's name. On 8/4/21 at 10:15 AM, the surveyor inspected the Heritage East medication cart #2 in the presence of LPN #2. The surveyor observed an opened vial of Humalog insulin that did not contained a label with a resident's name. [...]