Newark Nursing & Rehab

Inspectors wroteBased on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident had the right to choose schedules consistent with their interests. This affected one (#37) of three residents reviewed for activities of daily living choices. The facility census was 121.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a resident who was prescribed antipsychotic medications had appropriate documented indications for use of the medication. This affected one (#47) of one residents reviewed for medications. The facility census was 121.

Inspectors wroteBased on observation, medical record review, resident interview, resident family interview, staff interview, and policy review, the facility failed to ensure pressure ulcer treatments were completed as ordered and treatment supplies were handled in a manner to prevent contamination in order to promote healing of pressure ulcers. This affected two (#52 and #99) of three residents reviewed for pressure ulcers. The facility census was 121.

Inspectors wroteBased on observations, review of the medical record, review of the ambulatory wound clinic notes, review of the pharmacy delivery slips, review of the facility policy, review of facility emails, and interviews with staff, the facility failed to ensure a comprehensive initial wound assessment for a new wound was completed, wound treatments were completed as ordered, the physician was notified of absent dressings, wound interventions were in place and initiated timely, the wound was adequately assessed for appropriate wound staging, imaging services were completed as ordered, and infection control was maintained during wound care, to prevent the in-house development and/or worsening of a pressure ulcer to the coccyx of Resident #01. [...]

Inspectors wroteBased on observation, review of facility water temperature logs, review of the facility policy, and interview, the facility failed to maintain appropriate water temperatures on the hallway with rooms including Room Numbers 100, 101, 102, 103, 104, 105, 107, 473, 474, 475, and 476. This affected four residents (#22, #38, #57, and #61) out of four residents reviewed for environment, and had the potential to affect all 10 residents (#3, #9, #12 #22, #36, #38, #49, #57, #61, and #87) on the 100 and 400 hallway. Findings Include: Review of the weekly tap water temperature logs from 03/07/26 through 06/13/26 revealed no temperature or room number were documented it just indicated the temperatures were checked and were within normal limits. Observation on 06/13/26 at 8:50 A.M. [...]

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to provide resident and resident representatives with written notice of discharge. This affected one (Resident #116) of three residents reviewed for resident rights. The facility census was 115 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to implement behavioral management interventions for dementia residents. This affected one (Resident #116) of three residents reviewed for behavior management. The facility census was 115 residents.

Inspectors wroteBased on medical record review, observation staff interview, and review of the facility policy, the facility failed to ensure staff practiced proper hand hygiene during care. This affected two residents (Resident #58 and #74) of the three residents reviewed for wounds and incontinence care. The facility census was 115 residents.

Inspectors wroteBased on observations, staff interviews, and review of facility policies, the facility did not provide a safe, clean, and homelike environment by maintaining the building in good repair. This had the potential to affect all 120 residents living in the facility. The facility census was 120. Observation of the facility on 03/02/26 at 8:37A.M. to 9:39 A.M. revealed the following: -Observation of the 600-unit resident shower room revealed there was cracked tiles along the wall directly adjoining the floor. The cracked tiles were on the far wall from the desk area and around the toilet. There was a black and brown substance on eleven tiles to the left of the toilet and two cracked tiles, one cracked tile which was the fifth tile up the wall next to the inoperable shower which had equipment in it and rust on the facet handles. The shower room sink was leaking water and did not turn off. [...]

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had two medication errors of 34 opportunities for an error rate of 5.8%. This affected two Residents (#50 and #545) of three residents observed for medication administration. The facility census was 120 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent significant medication errors when staff did not administer insulin as ordered and did not prime insulin prior to administration. This affected two (Residents #50 and #545) of three residents reviewed for medication administration. The facility census was 120.1. Review of the medical record for Resident #50 revealed an admission date of 08/20/19 with diagnoses to include but not limited to type two diabetes mellitus with hyperglycemia, muscle weakness, diastolic heart failure, chronic pancreatitis, toxic liver disease, cardiomyopathy, hyperlipidemia, hypertension, spinal stenosis, need for assistance with personal care, vascular disease, hypotension, gastro-esophageal reflux disease, and atrial fibrillation. [...]

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure appropriate incontinence care was provided for one Resident # 910. This affected one (Resident #910) of the three residents reviewed for incontinence care. Additionally, the facility failed to ensure staff handled medication in a sanitary way. This affected one (Resident #205) of three residents observed for medication administration. The facility census was 120.

Inspectors wroteBased on interview, record review, hospital record review, facility policy review, review of Centers for Disease Control (CDC) Stimulant Guide, and review of SAMHSA (Substance Abuse and Mental Health Services Administration) guidelines, the facility failed to ensure a resident with history of substance use received the appropriate care to manage his condition or attain the highest practicable mental and psychosocial well-being. This affected one resident (Resident #82) of three residents reviewed for neglect. Findings Include:Review of the medical record for Resident #82 revealed an admission date of [DATE]. The facility listed diagnoses as of [DATE] that included paraplegia, anxiety disorder, insomnia, depression, chronic pain syndrome, and peripheral vascular disease unspecified. The diagnosis list did not include substance use disorder or a drug abuse diagnosis. [...]

Inspectors wroteBased on observation, record review, facility policy review, and interviews, the facility failed to ensure an adequate stock of controlled substances were on-hand to adequately treat pain. This affected two residents, Resident #46 and Resident #65. Actual Harm occurred when the facility failed to ensure scheduled pain medication was reordered timely and available for Resident #65 and Resident #46. Resident #65's pain medication was not documented as administered on 08/09/25, 08/10/25, 08/11/25, and 08/12/25 leading to Resident #65 reporting pain, rating the pain a ten on a one to ten scale, with 10 being the worst pain ever experienced. Resident #65's pain medication was not documented as administered and on 08/11/25 at 10:43 A.M. and 12:01 P.M., Resident #46 reported constant and intense pain in the legs where an amputation had been performed. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean kitchen environment. This had the potential to affect all 105 residents residing in the facility who received meals from the facility kitchen. The facility census was 105.

Inspectors wroteBased on medical record review, controlled substance log review, staff interview, and facility policy review, the facility failed to ensure residents were free from significant medication errors related to controlled medications. This affected six residents (#1, #3, #36, #62, #93, and #108) of seven residents reviewed for medication administration. The facility census was 105.

Inspectors wroteBased on record review and interview, the facility failed to have resident funds available to the residents on the weekend. This affected one resident (#15) and had the potential to affect all residents with funds managed by the facility. The facility census was 105.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) assessments were accurately completed. This affected three residents (#7, #13, and #15) out of five residents reviewed for accurate PASARR assessments. The facility census was 105.

Inspectors wroteBased on record review and interview, the facility failed to complete a baseline care plan for Resident #2 within 48 hours of admission as required. This affected one resident (#2) of four residents reviewed for dementia care. The facility census was 105.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan included comprehensive psychosocial interventions to address identified behaviors. This affected one resident (#64) out of thirty residents reviewed for care planning. The facility census was 105.

Inspectors wroteBased on medical record review, and staff interview, this facility failed to ensure care plans had been revised to accurately reflect enhanced barrier precautions and fluid restrictions had been discontinued. This affected two residents (#24 and #66) of 30 residents reviewed for care planning. The facility census was 105.

Inspectors wroteBased on medical record review, observations, and staff interview, the facility failed to ensure fall interventions were in place. This affected two residents (#1 and #43) of five residents reviewed for fall safety. The facility census was 105.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure nutritional supplements were implemented upon dietician and dialysis center recommendations for Resident #6. Additionally, the facility failed to implement interventions to prevent further weight loss for Resident #35. The affected two residents (#6 and #35) out of five residents reviewed for nutrition. The facility census was 105.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #79's medical record included a physician order for hemodialysis treatments. This affected one resident (#79) of two residents reviewed for dialysis. The facility census was 105.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the physician visited residents at the required frequency. This affected one resident (#2) of four residents sampled for dementia care. The facility census was 105.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure pharmacy recommendations that were addressed by the physician were implemented in a timely manner. This affected one resident (#43) of five residents reviewed for unnecessary medications. The facility census was 105.

Inspectors wroteBased on medical record review, hospice records, staff interview, and facility policy review, the facility failed to ensure hospice records were available for review to allow for effective collaboration between the facility and the hospice provider. This affected one resident (#43) of one resident reviewed for hospice care. The facility census was 105.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure Resident #75's wound and living space were free from pests. This affected one resident (#75) of six residents sampled for wounds. The facility census was 105.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure comprehensive care plans were developed in the areas of diabetes, depression, anticoagulants, activities, and skin picking behaviors. This affected five residents (#2, #33, #56, #84, and #85) of thirty residents reviewed for care planning. The facility census was 102.

Inspectors wroteBased on observation, medical record review, interview, and review of scheduled activities, the facility failed to ensure residents were offered or assisted in attending activities and failed to provide activities as scheduled. This affected four (#14, #22, #406, #52) of five residents reviewed for participation in activities. The facility census was 102.

Inspectors wroteBased on observations, staff and resident interviews, review of lunch meal tickets, review of the dietary spreadsheet, review of the menu, review of the emergency food menu, and facility policy review, the facility failed to ensure two residents (Residents #22 and #33) received all the foods as ordered according to their meal tickets and the facility failed to ensure there was an emergency food stock in a designated area of the facility. The deficient practices affected two residents (Residents #22 and #33) and had the potential to affect all of the residents who resided at the facility, except Resident #93 who had an ordered nothing by mouth (NPO) diet. The facility census was 102. Findings Include: [...]

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to ensure pureed foods were prepared to an appropriate texture, requiring surveyor intervention. The deficient practice had the potential to affect four residents (Residents #8, 22, 46, and 60) who had an ordered pureed diet. The facility census was 102. Findings Include: Observation on 08/27/24 at 10:23 A.M. of the preparation of pureed foods with [NAME] #201 revealed the cook placed six barbecue hamburgers into the blender and started blending. At 10:36 A.M., [NAME] #201 stopped the blender and poured the pureed barbecue hamburgers into a silver serving dish. [NAME] #201 tasted the pureed food item and confirmed she felt it was an appropriate at serve to the residents. There was no other staff present at the time of the observation to taste the pureed food. [...]

Inspectors wroteBased on review of the arbitration agreement and staff interview, the facility failed to ensure the arbitration agreement notified residents of their right to rescind the agreement within 30 days. The deficient practice affected 51 residents (Residents #2, 6, 10, 11, 14, 16, 21, 22, 29, 31, 34, 35, 42, 43, 44, 47, 48, 50, 51, 56, 58, 64, 66, 67, 69, 70, 71, 72, 73 74, 77, 78, 79, 81, 82, 83, 84, 86, 87, 88, 89, 91, 92, 97, 98, 100, 101, 405, 406, 407, and 409) who agreed to enter into the arbitration agreement. The facility census was 102. Findings Include: Review of the facility Arbitration Agreement, Agreement to Resolve Legal Disputes through Binding Arbitration, undated, revealed the agreement did not inform residents of their right to rescind the agreement within 30 days of signing the agreement. Interview on 08/27/24 at 5:02 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #406 was clean shaven, as preferred. This affected one resident (#406) of five residents reviewed for activities of daily living. The facility census was 102.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure skin assessments and monitoring were completed. This affected two residents (#3 and #84) of three residents reviewed for skin conditions. The facility census was 102.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure Resident #52 was given the opportunity to wear her recommended palm guard. This affected one resident (#52) of one residents reviewed for limited range of motion (ROM). The facility census was 102.

Inspectors wroteBased on observations, interview, medical record review, and facility investigation review the facility failed to maintain adequate supervision to ensure Resident #78 did not leave the facility's secured unit and complete a thorough investigation into her unsupervised departure from the secured unit. The facility also failed to ensure a safe environment for Resident #29. This affected two (Resident #29 and Resident #78) of seven residents reviewed for accidents. The facility census was 102.

Inspectors wroteBased on interview and record review revealed the facility failed to provide timely treatment for Resident #85's urinary tract infection (UTI). This affected one resident (#85) of four residents reviewed for UTI's. The facility census was 102.

Inspectors wroteBased on observation, interview, and record review the facility failed to care plan and implement interventions for Resident #86's autism and failed to monitor and effectively treat his anxiety. This affected one resident (#86) of three reviewed for mood and behaviors. The facility census was 102.

Inspectors wroteBased on interview and review of medical records the facility failed to ensure #56 who was on anticoagulants were monitored for side effects of the medication and had care plans in place for the anticoagulant. This affected one resident (#56) of five residents reviewed for unnecessary medications. The facility census was 102.

Inspectors wroteBased on interview and record review revealed the facility failed to monitor behaviors for Residents' #22, #56, and #306 who were receiving psychotropic medications. This affected three residents (#22, #56, and #306) of five reviewed for unnecessary medications. The facility census was 102.

Inspectors wroteBased on observation, interview, manufacturer guidelines, and facility policy review the facility failed to remove expired medications and securely store multi-use insulin vials. This deficient practice had the potential to affect any resident requesting flu vaccination, any new admission requiring tuberculosis (TB) testing, and affected one resident (Resident #84) out of four residents reviewed during medication administration. The facility census was 102. Findings Include: a) An observation on 08/26/24 at 10:09 A.M. revealed in Unit one's medication storage refrigerator an opened multi-use vial of Tubersol (tuberculosis (TB)) solution with out an opened date on either the vial or the packaging box. The TB solution had an expiration date of 04/2007 and had been dispensed from the pharmacy on 02/24/24. Interview on 08/26/24 at 10:09 A.M. [...]

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to ensure proper hand hygiene was conducted during meal service, and failed to ensure Enhanced Barrier Precautions (EBP) were implemented. This deficient practice had the potential to affect residents residing on the Memory Unit and had affected two residents (Resident #62 and #406) out two residents reviewed for EBP implementation. The facility census was 102. Findings Include: An observation on 08/26/24 at 8:18 A.M. during breakfast meal service on the Memory Unit revealed State Tested Nursing Assistants (STNAs) #224 and #244 serving the meal trays to residents sitting in the dining room on the memory unit. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to maintain a safe, functional home like environment. This deficient practice affected one resident (Resident #29) out of four residents reviewed for environment. Findings Include: An observation on 08/25/24 at 2:10 P.M. revealed in Resident #29's room the rubber toe plate covering at the bottom of the wall under the sink was loose and falling off the wall revealing moderate sized hole approximately three feet long extending from the end of the wall to the corner of the two walls. The hole was approximately two inches wide and was deep enough for the dry wall material and the wall support boards to be exposed. The rubber toe plate covering was also falling off the shorter wall to the right of the sink exposing the dry wall material behind the rubber toe plate covering. [...]

Inspectors wroteBased on interview, record review and policy review the facility failed to provide a written transfer notice when Resident #93 and Resident #103 were hospitalized . This affected two residents (#93 and #103) of two residents reviewed for hospitalizations. The facility census was 102.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to provide a bed hold notice when two residents (Residents #93 and #103) were hospitalized . The deficient practice affected two residents (Residents #93 and #103) of two reviewed for hospitalization. The facility census was 102. Findings Include: 1. Review of the closed medical record for Resident #103 revealed an admission date on 05/17/24 and a discharge date on 06/13/24. Medical diagnoses included displaced [NAME] fracture of left tibia, embolism and thrombosis of arteries of the lower extremities, severe protein-calorie malnutrition, anxiety disorder, and need for assistance with personal care. Review of Resident #103's clinical census revealed Resident #103 was hospitalized and discharged on 06/13/24. [...]

Inspectors wroteBased on record review, staff interview, review of the grievance log, review of a fall investigation, and facility policy review, the facility failed to timely notify one resident's (Resident #101) representative of a fall resulting in hospitalization. This affected one (Resident #101) of three residents reviewed for notification of changes. The facility census was 95. Findings Include: Review of the closed medical record for former Resident #101 revealed an initial admission date on 01/15/14, a readmission date on 04/16/16, and a discharge date on 01/03/24 due to passing away. [...]

Inspectors wroteBased on financial record review and staff interview, the facility failed to maintain resident financial records according to established standards. This affected 64 (Residents #19, #31, #86, #8, #81, #47, #1, #58, #21, #7, #53, #45, #10, #18, #39, #85, #36, #67, #74, #49, #2, #6, #69, #51, #34, #44, #80, #60, #5, #11, #77, #50, #88, #66, #55, #79, #75, #89, #90, #76, #32, #72, #40, #17, #38, #64, #28, #91, #71, #23, #70, #29, #9, #46, #78, #57, #20, #41, #92, #25, #65, #42, #13, and #43) of 64 residents who have personal funds accounts with the facility. The census was 85. Findings Include: Review of Residents #34, #80, #23, and #41 financial records revealed they did not have quarterly statements available for review. Two more residents were requested, and they were not available for review as well. Interview with Administrator on 10/12/22 at 2:27 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow droplet precautions during meal pass and did not implement isolation precautions for Resident #72 as ordered. This affected seven residents (#12, #72, #73, #83, #84, #285, and #286) and had the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on record review, review of liability notices, review of quarterly statements, resident interview, and staff interview, the facility failed to ensure residents received the appropriate liability notices when their Medicare (MCR) Part A services ended and ensure a Medicaid (MCD) eligible resident received appropriate notification of charges. This affected three (Resident #32, #37, and #65) of three residents reviewed for liability notices and one (Resident #60) of one residents reviewed for resident billing and charges.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure their consulting pharmacist made recommendations for gradual dose reduction (GDR) attempts with the use of psychotropic medications as required during their monthly medication regimen review. The facility also failed to ensure pharmacy recommendations were followed up on or responded to timely by the physician. This affected four (Resident #4, #47, #54 and #60) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate and complete records relating to catheter care for Resident #60, diagnoses for Resident #28, hospitalization for Resident #62, and hospice for Resident #81. This affected four residents (#28, #60, #62, and #81) of 27 records reviewed. The facility census was 85.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #60 was treated with respect and allowed to control the temperature in her room. This affected one resident (#60) of two reviewed for dignity. The facility census was 85.

Inspectors wroteBased on financial record review and staff interview, the facility failed to provide evidence that spend down notifications were given as required. This affected seven (Residents #45, #34, #80, #38, #64, #23, and #41) of 64 residents who have personal funds accounts with the facility. The census was 85. Findings Include: Review of the following residents personal funds accounts revealed they had a total amount of money within $200 of the allowed amount ($2,000), and there was no evidence the facility had provided the resident with a spend down notification: Resident #45 had a current total amount of $2,121.92 in her personal funds account. Resident #34 had a current total amount of $3,210.99 in her personal funds account. Resident #80 had a current total amount of $9,187.03 in her personal funds account. Resident #38 had a current total amount of $2,509.55 in her personal funds account. [...]

Inspectors wroteBased on medical record review, staff interview, and refusal of care policy review, the facility failed to ensure the physician was notified of a resident's refusal of medication. This affected one (Resident #85) of the one resident reviewed for physician notification. The facility census was 85.

Inspectors wroteBased on interview and record review the facility failed to complete Pre-admission Screening and Resident Review (PASARR) timely for Resident #12 and accurately for Resident #28. This affected two residents (#12 and #28) of four reviewed for PASARR's. The facility census was 85.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure residents had active care plans in place in the areas of contractures and oxygen use. This affected three (Resident #9, #54 and #73) of 27 residents reviewed for care plans.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure care planning conferences were held for residents and residents and/ or their families were invited to attend. This affected two (Resident #27 and #39) of two residents reviewed for care planning conferences.

Inspectors wroteBased on record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident was provided assistance with showers/ bathing as desired. This affected two (Residents #9, and #20) of four residents reviewed for activities of daily living (ADL's).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate care for Resident #54 and Resident #73 who had contractures. This affected two residents (#54 and #73) of two residents reviewed for limited range of motion. The facility census was 85.

Inspectors wroteBased on observation, interview, and record review revealed the facility failed to ensure Resident #60 received the required two-person assistance with transfers. This affected one resident (#60) of four reviewed for accident hazards. The facility census was 85.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident received oxygen at the appropriate flow rate as ordered by the physician. This affected one (Resident #9) of three residents reviewed for respiratory care.

Inspectors wroteBased on record review, staff interview and review of the facility's drug reference information, the facility failed to ensure a resident receiving Digoxin had their apical pulse checked prior to the administration of the medication. This affected one (Resident #27) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents receiving psychotropic medications had an adequate indication for use, gradual dose reductions (GDR's) were attempted, and were monitored appropriately for side effects associated with their use. This affected two (Resident #4 and #54) of five residents reviewed for unnecessary medications.