Total Rehab Moorestown

Inspectors wroteComplaints: NJ1875890, 2681814 Based on interviews, review of medical records, and review of facility documents, it was determined that the facility failed to develop and follow adequate fall prevention interventions on the care plan of a resident (Resident #2) who was at risk for falls. This deficient practice was identified for 1 of 3 residents (Resident # 2) reviewed for accidents and was evidenced by the following:A review of the admission Record for Resident #2 revealed the resident was admitted to the facility with diagnoses that included but were not limited to acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (condition where the heart does not pump blood as well as it should); type 2 diabetes mellitus without complications (condition where the body cannot use insulin correctly and sugar builds up in the blood); muscle weakness; [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure personal privacy was maintained when implementing a video monitoring device and ensured written consent was obtained prior to implementing video monitoring devices inside resident rooms for 2 of 2 units and for 2 of 2 residents reviewed for Resident Rights (Resident #25 and 40). The deficient practice was evidenced by the following: On 04/10/25 at 8:22 AM, the surveyor observed a camera device across from Resident #25 who was awake and in bed. Resident #25 appeared confused and did not engage with the surveyor at that time. On 04/11/25 at 11:49 AM, the surveyor conducted a telephone interview with the Responsible Party (RP) for Resident #25. The surveyor asked the RP if they had placed a camera device in the room and the RP stated, no, the facility placed the camera. On 4/11/25 at 12: [...]

Inspectors wroteBased on interview and review of documents it was determined that the facility failed to ensure who required Medicaid were admitted to the facility per their SNF/NF (Skilled Nursing Faciality/Nursing Facility) designation with the Centers for Medicare/Medicaid (CMS) and per the New Jersey Department of Health (DOH). The deficient practice affected all residents admitted to the facility and was evidenced by the following: Reference: Certificate of Need approval dated [DATE] and signed by the Acting Deputy Commissioner of the DOH, Health Systems revealed: .Approval of this application is conditioned upon the applicant's compliance with the following: Approval of the relocation of the 120 LTC (Long Term Care) bed .is subject to [company name redacted] satisfying the Medicaid-eligible resident utilization requirement at N.J.A.C. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to limit the potential spread of infection by failing to ensure a) appropriate transmission based precautions (TBP) were in place and consistently followed during a Covid-19 outbreak, b) staff consistently utilized Personal Protective Equipment (PPE) appropriately, and c) appropriate hand hygiene was performed and shared medical equipment was appropriately disinfected during the medication administration observation for Resident #40 and Resident #45 and for 2 of 2 residents reviewed for Covid-19 (Resident #8 and # 222). This deficient practice had the potential to affect all residents residing on 2 of 2 units and was evidenced by the following: [...]

Inspectors wroteBased on observation, interview and documents review it was determined the facility failed to identify the causal factor for falls (including falls with injury) and implement interventions, which included adequate supervision, to prevent further falls for a resident who was moderately cognitively impaired and sustained falls on [DATE], [DATE] and [DATE]. The deficient practice occurred for 1 of 4 residents reviewed for accidents (Resident #40) and was evidenced by the following: On [DATE] at 9:36 AM, the surveyor observed the resident resting in bed and was holding the television (TV) remote. The resident communicated they were hard of hearing and could hear better on left ear and was unable to turn the volume up on the TV. There appeared to be a camera in the resident's room opposite of the bed. On [DATE] at 9:40 AM, the surveyor observed the resident in bed and was calling for help. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure that an indwelling urinary catheter drainage bag was stored in a manner to prevent potential urinary tract infections. This deficient practice was identified for 1 of 1 resident reviewed with an indwelling urinary catheter (Resident #20), and was evidenced by the following: On 4/10/25 at 8:55 AM, the surveyor entered the room and observed Resident #20 in bed. The resident had a Foley catheter (medical device that helps drain urine from the bladder) drainage bag was resting directly on the floor. On 4/10/25 at 9:00 AM, the surveyor exited the room and asked a Certified Nursing Aide (CNA) in the hallway to assist with an observation of Resident #20. The surveyor along with the CNA, Director of Nursing (DON) put on personal protective equipment (PPE) and entered the room. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure the daily posting of licensed nurses, certified nursing aide staffing, and the resident census for 2 of 6 observations This deficient practice was evidenced by the following: On 4/15/25 at 12:00 PM, the surveyor observed a Nursing Home Resident Care Staffing Report (NHRCSR) which was posted on the wall, in the reception area of the lobby. The NHRCSR posted for day shift from 7:00 AM through 7:00 PM and night shift 7:00 PM through 7:00 AM were dated 4/13/25. There was no NHRSCR posted for 4/15/25 day shift 7:00 AM through 7:00 PM. On 4/15/25 at 12:01 PM, during an interview with the surveyor, the receptionist stated the Staffing Coordinator (SC) was responsible for posting NHRCSR daily. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that a medication was administered according to physician orders and acceptable standards of practice in accordance with the New Jersey Board of Nursing. This deficient practice was identified in one (1) of three (3) residents (Resident #40) observed during the medication observation pass. 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 observation, interview, and record review, it was determined that the facility failed to properly label, store, and dispose of medications in three (3) of eight (8) medication carts inspected. This deficient practice was evidenced by the following: On [DATE] at 11:00 AM, the surveyor inspected the 3 D high-side medication cart in the presence of a Licensed Practical Nurse (LPN#1). The surveyor observed an opened Heparin multi-dose vial that had no opened date and an unopened vial of Lantus insulin that was not dated and was stored in the medication cart. At that time, the surveyor interviewed LPN#1 who acknowledge that an opened vial of multi-dose Heparin should have been dated after opening and an unopened vial of Lantus insulin should have been stored in the refrigerator. On [DATE] at 11:15 AM, the surveyor inspected the 3 D low-side medication cart in the presence of LPN#2. [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of pertinent documentation, it was determined that the facility failed to a.) ensure a cognitively impaired resident (Resident #222) with a history of aspiration (inhaling food and liquids into the lungs) without a sensory response (reaction to a stimuli) and who was at risk for aspiration, received the appropriate physician ordered nectar thickened liquids (liquid thickened with an agent for a nectar-like consistency) and b.) ensure special dietary instructions of no straws were followed according to Resident # 171's treatment plan. This deficient practice was identified for 2 of 2 residents reviewed for food (Resident #171 and Resident #222), and was evidenced by the following:1. [...]

Inspectors wroteComplaint #: NJ 170732 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care and personal hygiene care for 7 of 13 residents (Resident #15, #66, #73, #76, #81, #169 and #322) reviewed for Activity of Daily Living Care, and for 2 of 2 resident units (2nd and 3rd Floor). The deficient practice was evidenced by the following: On 4/10/25 at 8:16 AM Surveyor #1 entered the 300's wing and observed a strong smell of feces and urine permeating throughout the hallway by the lower numbered rooms. Surveyor #2: 1. On 4/10/25 at 8:18 AM, Surveyor #2 observed Resident #15 sitting in a wheelchair in the room and was calling for help. Surveyor #2 entered the room and the resident stated that they needed to go to the bathroom. [...]

Inspectors wroteBased on observation, interview and review of the medical records and other facility documentation, it was determined that the facility failed to clarify a physician's order from 10/25/23 until 11/30/23 for 1 of 4 residents (Resident #94) observed during medication observation. This deficient 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 facility documents, it was determined that the facility failed to promptly record the removal of controlled drugs from the narcotic inventory record for 1 of 3 nurses observed during medication pass observation. This deficient practice was evidenced by the following: On 11/30/23 at 9:40 AM, the surveyor asked the Licensed Practical Nurse (LPN) to complete a narcotic count for the third-floor medication cart labeled High Cart C. As the surveyor and the LPN proceeded to conduct the narcotic count the surveyor discovered that the Controlled Drug Record (CDR) sheet for the narcotic medication named Lacosamide 100mg tablets (medication used to control seizures) for Resident #80 indicated that there should have been 25 tablets available, however there was only 24 tablets in the pill packet. [...]

Inspectors wroteBased on observation, interview, and pertinent facility policies, it was determined that the facility failed to a.) secure a medication administration cart during the medication pass conducted on [DATE] and b.) maintain medications with appropriate label/dating for 2 of 8 medication administration carts inspected This deficient practice was evidenced by the following: 1.) On [DATE] at 9:40 AM, the surveyor observed the medication storage cart on the third floor labeled High Cart C. During the inspection Licensed Practical Nurse (LPN #2) proceeded to walk to the medication storage room with the surveyor and away from the medication cart without locking and securing it. The surveyor went over to the medication cart to wait for the LPN's return from the storage area. When LPN #2 returned to High Cart C, the surveyor asked LPN #2 if the medication cart should be unlocked. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices to prevent the spread of infection. This deficient practice was identified for 1 of 3 nurses observed during a medication administration observation. The deficient practice was evidenced by the following: On 11/30/23 at 9:44 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medications to Resident #419. The Department Nurse Manager (DNM), with an ungloved hand, handed the LPN three (3) packets of medication for Resident #419. The medications received by the LPN included one (1) buspirone HCL oral tablet 5 milligram (mg), one (1) folic acid oral tablet 1 mg, and one (1) nifedipine 30mg 24hr extended-release oral tablet. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to notify CMS (Centers for Medicare & Medicaid Services) and receive authorization for a change in the facility's name in accordance with 42 CFR (Code of Federal Regulations) 424.516. This deficient practice was evidenced by the following: According to 42 CFR 424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare Program: (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. [...]

Inspectors wroteBased on observation, interview, record review and review of facility documents, it was determined that the facility failed to follow professional standards of clinical practice during medication administration for 1 of 4 residents (Resident #23) observed for medication pass. 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 state: [...]