Morristown Post Acute Rehab and Nursing Center

Inspectors wroteBased on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to ensure implementation of interventions designed by the physical therapist to stimulate functional performance and prevent further decline. This deficient practice was identified for one (1) of three (3) resident reviewed for positioning and mobility (Resident #88) and was evidenced by the following: On 6/19/25 at 11:31 AM, during the initial tour of the second floor, the surveyor entered Resident #88's room. The resident was awake, alert, pleasant and had a breakfast tray in front of them with built up utensils (an adaptive eating utensils designed with molded plastic handles to assist individuals with limited or weakened grasping strength). No additional assistive device was observed on the resident. The surveyor reviewed the medical record for Resident #88. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation it was determined that the facility failed to ensure a resident with history of post-traumatic stress disorder (PTSD) received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. This deficient practice was identified for one (1) of five (5) residents (Resident #159) reviewed for unnecessary medications and was evidenced by the following: On 6/23/25 at 12:54 PM, the surveyor observed Resident #159 in bed and was reluctant to discuss their experience in the facility for fear of retaliation. The surveyor reviewed the medical record for Resident #159. [...]

Inspectors wrote4. The surveyor interviewed Resident #134 on 6/19/25 at 12:16 PM. The resident was seated in an armchair at the bedside and told the surveyor they received hemodialysis three times a week. A review of the electronic medical record revealed the following information. The 4/19/25 admission MDS assessment tool indicated the resident had no cognitive deficits as evidenced by a BIMS score of 14 of a possible 15. The June 2025 Order Summary Report included a 4/14/25 physician's order for Midodrine oral tablet (medication used to raise blood pressure) 5 mg. twice a day for hypotension (low blood pressure) hold for SBP (systolic blood pressure) above 130 millimeters of mercury (mmHg). [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to post the prior year's State of New Jersey (State) inspection results in an area that was readily accessible to residents, families, and the public. The deficient practice was evidenced by the following: On 6/24/25 at 10:30 AM, the surveyor held the resident council meeting and 4 of 5 residents, who were in attendance, voiced that they did not know where the survey results were located. 1 of 5 of the resident's stated that they thought the survey results were at the receptionist desk. On 6/24/25 at 11:30 AM, the surveyor could not locate survey results near the receptionists desk and could not locate them throughout he facility and the receptionist stated that they did not know where the survey results were located. [...]

Inspectors wroteBased on observation, record review, interview, and United States (U.S.) Food and Drug Administration (FDA) dish sanitation recommendations, the facility failed to ensure 1 of 1 dish machine and 1 of 1 three-compartment sink were utilized in accordance with FDA guidance to minimize the potential for foodborne illness. Specifically, the facility failed to ensure the low-temperature dish machine achieved recommended temperatures, failed to ensure sanitizer testing supplies were not expired, and failed to maintain the chemical concentration of sanitizer in the three-compartment sink. The failed practices had the potential to affect 194 residents who received meals from the dietary department out of a total census of 199 residents.

Inspectors wroteBased on observation, record review, interview, facility policy review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and (&) Oversight Group (QSOG) memoranda, the facility failed to ensure CDC guidance and the facility's infection prevention and control (IPC) policies were promptly and consistently implemented, as evidenced by: 1) failure to ensure staff donned the appropriate personal protective equipment (PPE) while caring for 3 (Residents #1, #2, and #3) of 3 residents reviewed for enhanced barrier precautions (EBP. [...]

Inspectors wroteComplaint #: NJ00178715 Based on interview, record review, and review of facility's pertinent documentation on 11/06/2024, it was determined that the facility failed to obtain physician orders for laboratory services performed on 3 of 4 residents (Resident #1, Resident #2, and Resident #3) reviewed for laboratory services and physician orders. The deficient practice was evidenced by the following: 1. According to Resident #1's admission Record (AR), Resident was admitted to the facility with the following diagnoses that included but not limited to: Urinary Tract Infection, Hydronephrosis with Renal and Urethral Calculous Obstruction, Hypertension, Hyperlipidemia, Anxiety Disorder, Depression, Benign Prostatic Hyperplasia, and Congestive Heart Failure. [...]

Inspectors wroteCOMPLAINT # NJ176547 CENSUS: 192 SAMPLE SIZE: 3 Based on observation, interview, and record review, it was determined that the facility failed to provide appropriate incontinence care and double diapering a dependent resident who required staff assistance. This deficient practice was identified for 1 of 3 residents reviewed for bladder and bowel incontinence (Resident #2) and was evidenced by the following: According to the admission Record, Resident #2 was admitted to the facility on [DATE], with diagnoses which included but were not limited to: Traumatic Subdural Hemorrhage without loss of Consciousness, [NAME] Syndrome, Acute and Chronic Respiratory Failure with Hypoxia, Persistent Vegetative State, Cerebral Stroke Syndrome, Gastrostomy Status, Tracheostomy Status, Essential Primary Hypertension. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify the need for a new Preadmission Screening and Resident Review (PASARR-a screening which looks for indicators that a person may have intellectual disability, related disability, or serious mental illness) when a resident had a new diagnosis of mental illness for one (Resident (R) 23) of three sampled residents in a total sample of 42. This failure placed the residents at risk of not receiving necessary services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the PASARR (Pre-admission Screening and Resident Review-a screening process for residents who have indicators of intellectual disability, related disability, or serious mental illness) was followed for one (Resident (R) 43) of three sampled residents in a total sample of 42. The facility failed to ensure a PASARR Level 1 was corrected to include serious mental illness to determine if a Level II (a more in-depth screening) was required. This failure placed the resident at risk of not receiving the mental health services needed and placed him at risk for a diminished quality of life.

Inspectors wroteBased on observations, interviews, record review, and review of facility policies, the facility failed to ensure one resident (Resident (R) 118)'s out of four residents' had appropriate fall prevention interventions to prevent potential accident hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident (R) 15) of four sampled residents who were fed via a gastrostomy tube had the enteral feeding container labeled, dated, and timed, as required. This failure placed the resident at risk for having received expired and/or inaccurate enteral nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control standards were performed during intravenous (IV) medication administration for one (Resident (R) 196) of one resident reviewed for IV antibiotic medications. The facility failed to ensure proper glove use was used during IV medication administration. This failure placed the resident at risk for cross contamination from infectious agents.

Inspectors wroteComplaint # NJ00168549 and NJ00168552 Based on observation, interview, and review of pertinent facility documentation on [DATE], it was determined that the facility failed to implement its policy on Administering Medications and Physician Medication Orders for 4 of 4 resident residents (Resident #1, Resident #2, Resident #3, and Resident #4). This deficient practice was evidenced by the following: During the entrance conference on [DATE] at 9:40 a.m., the Licensed Nursing Home Administrator (LNHA) revealed that LPN #1 was the previous unit manager of XX floor and was currently acting as the facility's Infection Control Preventionist (ICP). During the tour of the XX floor on [DATE] at 9:59 a.m. the Surveyor interviewed LPN #1. LPN #1 introduced herself as the floor LPN/Unit Manager (UM) and the facility's ICP. [...]

Inspectors wrote3.) On 07/27/21 at 9:39 AM, Surveyor #2 observed Resident #63 in a wheelchair in his/her room. Surveyor #2 observed the resident's finger nails were visibly long and extended above his/her finger tips, with a visible dark debris under all ten nails. Resident #63 stated to Surveyor #2 that he/she would like to have his/her finger nails cut but couldn't recall if he/she had ever asked any of the staff. On 07/28/21 at 10:48 AM, Surveyor #2 made a second observation of Resident #63 while the resident was sitting in a wheelchair in their room. Resident #63's finger nails remained visibly long with debris observed under the nails. On 07/29/21 at 10:03 AM, Surveyor #2 made a third observation of Resident #63 while sitting in a wheelchair in his/her room. Surveyor #2 observed Resident #63's nails remained visibly long with debris observed under the nails. [...]

Inspectors wroteBased on observation, interview and document review, it was determined that the facility failed to maintain the kitchen in a clean and sanitary manner, and properly store potentially hazardous foods to ensure they are not used by a safe use by date to prevent the development of food borne illness. The deficient practice was evidenced by the following: On 07/27/21 from 8:50 AM to 10:32 AM the surveyor conducted a tour of the kitchen with the Food Service Director (FSD) and observed the following: 1. A walk in refrigeration unit, box #3, had stored items which included plastic bins of 4 ounce pre- packaged thin juices, thickened juices, 4 ounce yogurts and wrapped pre-made sandwiches. The FSD stated the refrigeration unit was used primarily for tray line items and was currently in operation. [...]

Inspectors wroteBased on observation, interview, record review and review of facility documentation, it was determined that the facility failed to follow facility policy and Centers for Disease Control and Prevention (CDC) guidelines to limit the potential spread of infection by failing to: [...]

Inspectors wroteBased on observation, interview, review of medical records and review of other pertinent documentation, it was determined that the facility failed to treat all residents in a dignified manner by: a.) applying multiple incontinent briefs to incontinent residents, b.) failing to provide incontinence care to a resident assessed to be dependent on staff for activities of daily living (ADL's ), c.) transporting a resident in a recliner chair backwards, d.) failing to clean blood off a resident's face, and e.) failing to maintain a resident's clothing, blanket, and wheelchair in a clean manner. This deficient practice was identified for 7 of 8 residents reviewed for dignity (Residents #29, #33, #45, #75, #76, #112, #129) on 2 of 4 nursing units and was evidenced by the following. [...]

Inspectors wroteBased on interview, record review and review of pertinent documents, it was determined that the facility failed to follow the facility abuse policy by failing to: a.) thoroughly investigate an allegation of a staff member injuring a resident as potential abuse, and b.) failed to investigate an injury of unknown origin. This deficient practice occurred for 2 of 2 residents investigated for abuse (Resident's #45 & #255) and was evidenced by the following: 1. On 08/03/21 at 10:44 AM, the surveyor observed Resident #45 in bed, the resident did not initially respond, held his/her head down and appeared guarded. At 10:49 AM the Certified Nurse Aide (CNA) assigned to Resident #45 entered the room. The CNA stated she completed all care for the resident except for feeding and the resident did not like to be touched. A review of the medical record for Resident #45 revealed the following: [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to: a.) ensure a resident who left the facility for hemodialysis treatments received physician ordered medications in coordination with the hemodialysis schedule, and in accordance with physician prescribed orders, b.) assess a resident who had a change in condition, and c.) ensure medications were administered, parameters were monitored as ordered, and the physician was notified regarding medications that were not administered per policy. The deficient practice occurred for 1 of 3 residents reviewed for hemodialyis (Resident #7), 1 of 32 residents reviewed for quality of care (Resident #112) and 1 of 1 closed records reviewed for resident death (Resident #155). The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was identified that the facility failed to a.) assess and document the development of a facility acquired pressure ulcer, b.) notify the physician of the development of the facility acquired pressure ulcer, and c.) obtain a physician ordered treatment for a facility acquired pressure ulcer. This deficient practice was identified for one of two resident's reviewed pressure ulcers, (Resident #129) and was evidenced by the following: Resident #129 was admitted to the facility with diagnoses which included, enterocolitis (inflammation of the digestive tract), diabetes mellitus, difficulty in walking, unspecified abnormality of gait (walking) and mobility, need for assistance with personal care. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation it was determined, that the facility failed to: a.) maintain adequate monitoring of a resident post dialysis treatment and b.) consistently document post dialysis treatment on the hemodialysis communication record. This deficient practice was identified for one of three residents reviewed, (Resident #7) for dialysis care and services and was evidenced by the following: On 07/27/21 at 10:45 AM, the surveyor observed Resident #7 in his/her room. The resident stated that he/she went to dialysis on Tuesday's, Thursday's, and Saturdays, was picked up by transport around 11:00 AM and would return to the facility around 5:00 PM. The resident showed the surveyor his/her fistula (a surgically made passage between an artery and a vein that functions as a dialysis access site) on his/her left forearm. [...]

Inspectors wroteComplaint #NJ 00146254 Based on observation, interview, and review of pertinent facility documentation it was determined that the facility failed to: a.) provide nursing and related services to assure the residents safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care in accordance with the facility assessment and b.) provide sufficient staffing numbers to meet minimum staffing requirements. This deficient practice was observed on 4 of 4 nursing units and for eight of 30 residents' reviewed, (Resident #7, #33, #45, #54, #63, #75, #76, and #129) for care related to staffing. Refer to F677, The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was identified that the facility failed to ensure that an insulin medication was administered to a resident within an appropriate time frame according to: a.) physician's order and b.) manufacturer specifications. This deficient practice was identified for 1 of 1 resident, (Resident #7) reviewed for the administration of an insulin medication, and was evidenced by the following: On 07/27/21 at 10:45 AM, the surveyor observed Resident #7 in his/her room. The resident stated that he/she went to dialysis on Tuesday's, Thursday's, and Saturdays, was picked up by transport around 11:00 AM and would return to the facility around 5:00 PM. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documentation, it was determined the facility failed to ensure residents received the correct physician ordered thickened liquids. This deficient practice was identified for 5 of 10 residents (Resident #30, #69, #93, #104, #112) on the third floor unit, reviewed for therapeutic diets. The deficient practice was evidenced by the following: On 07/30/21 at 8:41 AM, the surveyor observed a Styrofoam cup sitting on the the bedside table in Resident #69's room with the date of 07/30/21 written on it. Resident #69 was lying in bed and unable to reach the cup. The Director of Nursing (DON) was at the third floor unit nurse's desk at that time. The DON accompanied the surveyor to Resident #69's room and observed the Styrofoam cup sitting on Resident #69's bedside table. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe environment during medication administration. This deficient practice was identified for 1 of 32 residents reviewed (Resident #132). The deficient practice was evidenced by the following: Resident #132 was admitted to the facility with diagnoses which included, unspecified convulsions, hypertension, adjustment disorder, congestive heart failure and end stage renal disease. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 04/2021 and the Annual assessment dated 10/2021, revealed that Resident #132 was awake and alert. Resident #132 scored 15 on the Brief Interview for Mental Status (BIMS ) which indicated the resident was cognitively intact. On 07/30/2021 at 8:10 AM, the surveyor observed the nurse in the hallway at the medication cart. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to store urinary catheter drainage bags appropriately to limit the development of infection. This deficient practice was identified for 2 of 3 residents reviewed, (Resident #86 & Resident #106) for urinary catheter care, and was evidenced by the following: 1.) On 07/27/21 at 9:52 AM, surveyor #1 observed Resident #106 seated upright in a wheelchair in his/her room. The resident stated that he/she had resided at the facility for, awhile and had an indwelling urinary catheter. The resident then lifted his/her left pant leg and showed the surveyor a drainage bag attached to his/her left leg which contained clear, yellow urine. [...]

Inspectors wroteBased on observation, interview, record review and other document review, it was determined, that the facility failed to a.) administer the correct amount of oxygen (O2) to residents per the physician's order, b.) document the administration of O2 per physician's order, and c.) failed to date and sign the O2 tubing to verify that it was changed. This deficient practice was identified for 1 of 2 residents reviewed (Resident #130) for respiratory care and was evidenced by the following: According to admission Record (AR), Resident # 130 was admitted to the facility with the diagnoses that included but were not limited to: malignant neoplasm (cancer) of the rectum, diabetes mellitus (DM) and obesity. [...]