Bartley Nursing & Rehab

Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to provide an environment that is safe, functional, sanitary, and comfortable. This deficient practice was identified for two of three dining rooms (Main and Dogwood).This deficient practice was evidenced by the following: On 8/6/25 at 11:52 AM, the surveyor toured the facility's main dining room in the presence of the Activities Director (AD) and observed a bug in the second drawer of the kitchenette, as well as a black, ground substance in the fourth drawer, which the AD identified as coffee. The fourth drawer was also sticky to the touch. On 8/6/25 at 11:56 AM, in the presence of the Food Service Director (FSD), the surveyor observed that all five steam table wells in the Main and Dogwood dining rooms had residual water marks approximately half an inch above the water level. The wells also contained dirty water with food debris that was not consistent with the day's lunch meal. A review of the facility's Monthly Cleaning List for week one of 08/25 showed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and review of pertinent facility documents it was determined that the facility failed to interact with residents in a dignified and respectful manner by failing to provide privacy to Resident #8 during wound care. This deficient practice was identified for 1 of 44 residents reviewed for dignity and was evidenced by the following:During a tour of the Dogwood Unit on 8/5/2025 at 11:53 AM, the surveyor observed room [ROOM NUMBER] with the door open and two nurses inside performing wound care to Resident #8 whose bed was next to the window. The surveyor noted that resident's privacy curtain was not pulled and the window shades were not pulled down for privacy. The surveyor continued to observe the room and at no time was Resident #8's privacy maintained.On the same date at 12:01 PM, the surveyor approached the Assistant Director of Nursing (ADON) who was seated at the nursing station. The ADON stated that during wound care, privacy was to be maintained by either…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview, record review, and review of pertinent facility documents it was determined that the facility failed to provide appropriate and sufficient care urinary catheter care, specifically by having the catheter drain bag not secured in a manner to maintain infection control, outside of a privacy bag, and improperly positioned at the foot of the bed in manner to potentially cause pain to resident. The deficient practice was identified for 1 of 3 Residents (Resident # 13) reviewed for Urinary Catheter or Urinary Tract Infections and was evidenced by the following:During initial tour of the facility on 8/4/2025 at 10:52 AM, the surveyor observed the resident's catheter drainage bag draped over the foot of the Resident #13 bed. The draining catheter bag was not fully contained inside the privacy bag and resident's urine was visible inside the bag. The resident stated that he was not sure how long the drainage bag has been in this manner and confirmed that they do not have any pain at this current time. The surveyor reviewed the medical record for Resident #18.A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint NJ # 157609; 157901; 160396 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to administer medications within scheduled time parameters on various shifts for two residents in accordance with professional standards of practice. This deficient practice was identified for 2 of 35 residents reviewed for professional standards of practice (Resident #20 & Resident #213). 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 registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes, Annotated Title 45, Chapter 11 Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint NJ# 160883 Based on observations, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident received showers as scheduled. This deficient practice was identified for 1 of 2 residents reviewed for activities of daily living (Resident #61), and was evidenced by the following: On 4/15/24 at 11:01 AM, the surveyor interviewed Resident #61 who stated he/she did not receive their scheduled shower on Friday 4/12/24 during the 3:00 PM to 11:00 PM (3-11) shift. The resident stated their showers were scheduled weekly for Mondays and Fridays. The surveyor reviewed the medical record for Resident #61. A review of the admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), pleural effusion (a buildup of fluid between the tissue that line the lungs and the chest), diabetes mellitus, edema (swelling caused by too much fluid trapped in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness; b.) maintain kitchen equipment in a clean and sanitary manner; and c.) maintain cold food in acceptable temperatures during meal service. The deficient practice was evidenced by the following: 1. On 4/10/24 at 9:10 AM, the surveyor in the presence of the Food Service Director (FSD) and the Dietary Manager (DM) conducted a kitchen tour and observed the following: 1. In the walk-in freezer, an opened box of sliced cheese pizza. The box contained a bag with two slices of pizza outside of the bag, and the box was unsealed exposing the contents to air. The surveyor observed ice crystals on all the pizza slices. There was no observed date when the box was opened. The FSD was unsure when the box was opened. 2. In the walk-in freezer, an opened box of Salisbury steaks. The box contained a bag that was opened exposing the contents to air. The surveyor observed ice crystals on the food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review pertinent facility documents, it was determined that the facility failed to maintain complete and accurate skin assessments. This deficient practice was identified for 1 of 35 resident medical records reviewed (Resident #61), and was evidenced by the following: On 4/15/24 at 11:01 AM, the surveyor interviewed Resident #61 who stated he/she did not receive their scheduled shower on Friday 4/12/24. The surveyor reviewed the medical record for Resident #61. A review of the admission Record face sheet (an admission summary) revealed the resident was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), pleural effusion (a buildup of fluid between the tissue that line the lungs and the chest), diabetes mellitus, edema (swelling caused by too much fluid trapped in the body tissues), and end stage renal disease (the kidneys lose the ability to remove waste and balance fluids). A review of the most recent quarterly Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to ensure appropriate storage for respiratory equipment for infection prevention. This deficient practice was identified for 1 of 4 residents reviewed for respiratory care (Resident #61), and was evidenced by the following: On 4/15/24 at 11:01 AM, the surveyor observed Resident #61 in bed and their nebulizer mask and tubing placed directly on the nebulizer machine (a device used for producing a fine spray of liquids). Resident #61 informed the surveyor that after their nebulizer treatment (breathing treatment), they removed their nebulizer mask and placed it on the machine. On 4/15/24 at 11:15 AM, the surveyor interviewed the resident's License Practical Nurse (LPN) who stated she had administered the resident's nebulizer treatment earlier, but she never went back to the resident's room to verify if the treatment was completed. At that time, the LPN accompanied by the surveyor went into Resident #61's room, and the LPN took the resident's nebulizer mask off of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of other facility documentation it was determined that the facility failed to maintain the resident's environment, equipment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was identified for 1 of 4 nursing units (Birch Unit) and was evidenced by the following: On 4/10/24 at 10:35 AM, the surveyor entered resident room Birch #17 and observed the doorknob backplate was not secured properly to the resident's entrance door or bathroom door, which resulted in the backplate hanging loosely with a gap between the doorknob and the door. On 4/10/24 at 10:37 AM, the surveyor entered resident room Birch #15 and observed the doorknob backplate was not secured properly to the resident's entrance door which resulted in the backplate hanging loosely with a gap between the doorknob and the door. On 4/10/24 at 11:02 AM, the surveyor observed in resident room Birch #11, the packaged terminal air unit (PTAC) (a self-contained through-the-wall air conditioning and heating unit) with the cover detached and was placed next…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY COMPLAINT # NJ162053 Based on interviews, medical records review, and review of other pertinent facility documentation on 9/12/23, it was determined that the facility failed to follow their policies and procedures for a facility-initiated discharge. A resident (Resident #1) was involved in an altercation with another resident and sent to the hospital for a behavioral evaluation. When the resident was discharge from the hospital, the facility would not permit a return back to the facility. The deficient practice was identified for Resident #1, 1 of 3 residents reviewed for transfer/discharge and was evidenced by the following: According to the admission Record, Resident #1 was admitted to the facility on [DATE] with diagnoses which included but were not limited to lack of coordination, dementia with behavioral disturbances, schizophrenia, anxiety disorder, and Parkinson's Disease. Review of the admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 12/13/22, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and review of facility documentation, it was determined that the facility failed to ensure respiratory equipment was kept in a clean and sanitary condition, and stored properly to reduce the risk of infection for 1 of 1 residents reviewed for respiratory equipment, Resident #18. The deficient practice was evidenced as follows: According to the facility's admission Record, Resident #18 was admitted to the facility in 11/2019 with diagnoses which included but were not limited to: Chronic Obstructive Pulmonary Disease, Unspecified (a group of diseases that causes airflow blockage and breathing related problems). Review of a Quarterly Minimum Data Set (MDS), an assessment tool dated 11/30/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated that the resident's cognition was intact. Review of the resident's Order Summary Report revealed an order dated 11/25/21 for Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams per 3 milliliters orally via nebulizer (a machine that delivers aerosol medication) every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.