Redbank Center For Rehabilitation And Healing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure PRN (as needed) psychotropics were not prescribed beyond 14 days without documented rational, for one of five residents (Resident (R) 101) reviewed for unnecessary medications of 32 sample residents. This failure had the potential to contribute to excessive medication administration. Findings include: Review of the admission Record located under the Profile tab of the electronic medical record (EMR), revealed R101 was originally admitted to the facility on [DATE] with diagnoses that included depression, a history of mental and behavioral disorders, end stage renal disease, and general anxiety disorder. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/27/25 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. Review of R101's Order tab of the EMR, revealed an order for Clonazepam 2MG…

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 observation, record review, interview, and facility policy review, the facility failed to ensure medication administration was less than 5% error rate which included gabapentin, scheduled for every eight hours was administered one hour and 39 minutes after the scheduled time; calcium acetate, which had been discontinued, was administered; and one tablet of estradiol was administered instead of two for one of four residents (Resident (R) 101) observed during medication administration of 32 sample residents. Medication errors have the potential to result in adverse health outcomes. Findings include: Review of R101's admission Record under the electronic medical record (EMR) Profile tab, revealed she was admitted to the facility on [DATE]. R101 had diagnoses which included hypothyroidism and failure to thrive. Review of R101's Orders tab of the EMR, revealed orders which included: -Estradiol 2 milligrams (mg). Give two tablets daily and one tablet every evening, both ordered 12/31/24, for hormone…

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 observation, staff interview, and review of facility policy, the facility failed to ensure that three of six medication carts, located on all three floors of the facility, were secure when staff were not present. This had the potential to affect the health of all residents with medications on those carts and the safety of any resident who might open the cart and remove medications. Findings include: Observations of one of two medication carts on the third floor on 02/23/25 revealed: -From 11:25 AM until 11:34 AM, Registered Nurse (RN) 1 walked away and went into a resident's room leaving the medication cart unlocked. Five residents were seated in wheelchairs in the hall within twenty feet of the cart, located across the hall from the Dayroom. -At 11:34 AM, RN1 returned to the medication cart. RN1 removed medication and walked into another resident's room at 11:35 AM, leaving the cart unlocked and unattended. -From 12:20 PM until 12:24 PM, the medication cart was observed in the same location as previous…

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 record review, interview, and facility policy review, the facility failed to ensure complete records for two of four residents (Resident (R) 127 and R129) related to the death in facility for R127 and related to being discharged to the community for R129; reviewed for medical records of 32 sample residents. Failure to completely document the circumstances around resident discharge had the potential to result in staff not knowing why the resident was no longer in the facility; not knowing if the physician and family were notified; and potential legal ramifications. Findings include: 1. Review of R127's admission Record located in the Profile tab of the electronic medical record (EMR) revealed the resident was discharged on 12/29/24 at 7:20 AM and the resident was discharged to the funeral home. Review of the resident's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/24 and located under the MDS tab of the EMR, revealed she had a death in facility. Review of the EMR in…

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 interviews and review of pertinent facility documents, it was determined that the facility failed to complete and submit discharge Minimum Data Set Assessments (MDS), an assessment tool, as required for 17 of 17 residents (Resident #9, #17, #35, #47, #57, #82, #85, #93, #94, #96, #97, #98, #99, #100, #101, #102, and #110) system selected for MDS over 120 days and was evidenced by the following: On 1/4/23 at 10:32 AM, the surveyor interviewed the MDS Coordinator who stated she had been working alone on MDS for about five months, and the facility had been looking for additional help without success. At this time, the surveyor provided the MDS Coordinator with a list of thirty-seven system selected residents identified as having an MDS record that was over 120 days overdue. The MDS Coordinator was asked to provide the survey team with the date the last MDS was submitted and the next MDS that was due, as well as if the resident remained in the facility or had been discharged . On 1/5/23 at 9:14 AM, the surveyor interviewed the MDS Coordinator who stated that she had…

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 interview and review of pertinent facility documents, it was determined that the facility failed to conduct yearly performance reviews of Certified Nursing Aides (CNA) in order to provide specific education based on the outcomes of the reviews. This deficient practice was identified for 4 of 4 CNAs whose personnel records were reviewed and was evidenced by the following: 1. According to the data provided by the facility, CNA #1 was hired on 9/11/08. Review of CNA #1's personnel file reflected there was no current performance evaluations completed for CNA #1. 2. According to the data provided by the facility, CNA #2 was hired on 11/5/14. Review of CNA #2's personnel file reflected there was no current performance evaluations completed for CNA #2. 3. According to the data provided by the facility, CNA #3 was hired on 11/8/93. Review of CNA #3's personnel file reflected there was no current performance evaluations completed for CNA #3. 4. According to the data provided by the facility, CNA #4 was hired on 9/23/19. Review of CNA #4's personnel file reflected there were no…

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 employee staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service in the role of the Food Service Director (FSD) in the absence of a full-time Registered Dietitian. This deficient practice would affect all residents and was evidenced by the following: On 1/3/23 at 9:24 AM, the surveyor entered the kitchen and asked to tour with the FSD. The Dietary Aide (DA) stated he was temporarily filling in for the FSD who has been out on leave since May. The DA stated he had no certifications in dietary management, food service management and safety or have a degree in food service management. The DA stated he was employed at the facility for many years and was just helping while the FSD was out. The DA stated that a sister facility's FSD could help out and was certified. The surveyor asked if any of the other employees in the kitchen had food safety certification, and the DA stated no. The surveyor requested…

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.) ensure the dish machine in use maintained the appropriate temperature according to the manufacturer's specifications; b.) maintain multiuse food-contact surface cutting board in a manner to prevent microbial growth; c.) store, label, and date potentially hazardous foods to prevent food-borne illness; d.) discard potentially hazardous foods past their date of expiration; and e.) maintain storage areas in a sanitary manner. This deficient practice was evidenced by the following: On 1/3/23 at 9:24 AM, the surveyor entered the kitchen and asked to tour with the Food Service Director (FSD). The Dietary Aide (DA) stated he was temporarily filling in for the FSD who has been out on leave since May. The DA stated he had no certifications in food service management and safety, dietary management, or have a degree in food service management. The DA stated he was employed at the facility for many years and was just helping while the FSD was out. The DA stated that 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 observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the systemic implementation of their antibiotic stewardship program. This deficient practice was identified while reviewing Resident #29 for use of antibiotics for a urinary tract infection and has the potential to affect all residents. The evidence was as follows: On 1/3/23 at 12:02 PM, the surveyor observed Resident #29 lying in bed. The resident had a urinary catheter in a privacy bag that was positioned below the bladder. The surveyor reviewed the medical record for Resident #29. A review of the Resident Face Sheet (an admission summary) reflected the resident was readmitted to the facility in November of 2022 with diagnoses which included chronic obstructive pulmonary disease (condition involving constriction of the airways and difficulty breathing), Parkinson's disease (a progressive disorder that affects the nervous system and the part of the body controlled by nerves), and…

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 implement their abuse policy by ensuring all new employees were screened for potential abuse by conducting reference checks from previous and current employers. This deficient practice was identified for 4 of 5 staff (Staff #2, #3, #4, and #5) reviewed for newly hired employees and was evidenced by the following: On 1/9/23 at 2:50 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) to provide the survey team with the personnel and health files for five selected newly hired employees (Staff #1, #2, #3, #4, and #5) in the past four months. A review of the facility's HMNR Abuse Prevention policy dated 2022, included [facility name] will protect the resident/patient right to be free from verbal, sexual, physical, mental abuse, corporal punishment, misappropriation of property and involuntary seclusion .This policy will be accomplished through the seven components of abuse prevention: screening of potential staff .Screening: prospective…

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, interviews, and review of pertinent facility documents, it was determined that the facility failed to obtain weekly weights as ordered for newly admitted residents with significant weight loss. This deficient practiced was identified for 2 of 2 residents (Resident #19 and #59) reviewed for unplanned weight loss and was evidenced by the following: On 1/3/23 at 11:19 AM, the surveyor observed Resident #59 lying in bed asleep with an enteral formula (formula administered via tube feeding (a tube inserted into the stomach wall to provide nutrition)) hanging on a tube feeding pole not being administered. The resident appeared to be very thin. On 1/3/23 at 11:30 AM, the surveyor interviewed the Unit Manager/Licensed Practical Nurse (UM/LPN) who stated the Second-Floor nursing unit did not have a weight book for the residents' weights; she kept all the residents' weights on a spreadsheet on her personal computer. The UM/LPN stated she reviewed the weights and gave a copy of the weights to 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 the facility failed to a.) ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 1 of 1 forms provided; b.) ensure the DEA 222 forms were dated and signed as of the day it was submitted for filling for 4 of 7 forms provided; and c.) to accurately document the administration of controlled medication for 2 sampled residents (Resident #52 and Resident #61) identified upon inspection of 1 of 3 medication carts. The evidence was as follows: 1. On 1/6/23 at 9:43 AM, the surveyor reviewed the facility provided DEA 222 forms which revealed four of the seven provided forms had been pre-signed by the facility's Medical Director prior to submission to the provider pharmacy for filling. The forms were as follows: Order form number: 220240368; 220240367; 220317342; and 220317341. On 1/6/23 at 1:56 PM, the surveyor interviewed the Director of 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.

Based on observation and interview, it was determined that the facility failed to properly dispose and maintain waste in garbage dumpster areas. This deficient practice was identified for 5 of 6 garbage dumpsters in 1 of 2 garbage disposal areas and was evidenced by the following: On 1/4/23 at 8:15 AM, the surveyor observed the garbage dumpster area which contained five garbage dumpsters. Out of the five garbage dumpsters, one of the garbage dumpster's lids was opened exposing its contents. The surveyor observed high levels of debris surrounding all five garbage dumpsters on all four sides. The debris included but was not limited to disposable gloves, boxes, paper, bottles, and other debris. On 1/5/23 at 8:11 AM, the surveyor observed the garbage dumpster area which contained five garbage dumpsters. Out of the five garbage dumpsters, one of the garbage dumpster's lids was opened exposing its contents. The surveyor observed high levels of debris surrounding all five garbage dumpsters on all four sides. The debris included but was not limited to disposable gloves, boxes, paper,…

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 observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days. This deficient practice was identified for 1 of 24 residents (Resident #19) reviewed for physician visits and evidenced by the following: On 1/3/23 at 10:57 AM, the surveyor observed Resident #19 lying in bed asleep. The resident appeared to be thin. The surveyor reviewed the medical record for Resident #19. A review of the Resident Face Sheet (an admission summary) reflected the resident was admitted to the facility in October of 2016 with diagnoses which included iron deficiency anemia, type II diabetes mellitus, schizoaffective disorder, and bipolar II disorder. A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 10/11/22, reflected the resident had a brief interview for mental status (BIMS) score…

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 follow a physician's order for no cheese by ensuring a resident did not receive cheese tortellini which was listed on their meal ticket preference as no cheese. This deficient practice was identified for 1 of 2 residents (Resident #23) reviewed for food choices, and was evidenced by the following: On 1/3/23 at 11:22 AM, the surveyor observed Resident #23 awake lying in bed. The resident informed the surveyor he/she was unhappy with the kitchen because they sent inappropriate foods to them. The resident continued they had a recent diagnosis of lactose intolerance and was supposed to receive lactaid milk and no cheese. The resident stated the facility sent them dishes with cheese last week which included chicken cordon blue and pizza. The resident stated he/she informed the kitchen and as an alternative was given a burger with no bun because the kitchen did not have any buns. The resident stated his/her meal ticket also indicated no corned beef and he/she received…

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 maintain infection control standards of practice and procedures to prevent the risk of infection and promote healing. This deficient practice was identified for 1 of 1 residents (Resident #33) observed during wound treatments and was evidenced by the following: On 1/4/23 at 10:14 AM, the surveyor observed Resident #33 in bed with his/her eyes open. The resident did not respond to the surveyor. The surveyor reviewed the medical record for Resident #33. A review of the Resident Face Sheet (an admission summary) reflected that the resident was admitted to the facility in July of 2017 with diagnoses that included parastomal hernia (incision that allows protrusion of abdominal contents through the abdominal wall), infection, colostomy (surgical procedure connecting the colon to the abdominal wall), schizophrenia, intestinal obstruction, and dysphasia (difficulty swallowing). A review of the annual Minimum Data Set (MDS), an assessment tool dated 7/25/22, reflected…

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 medical record review, and other facility documentation, it was determined that the facility failed to a.) transcribe orders to the electronic physician's orders and medication administration record (eMAR), for 1 of 4 residents reviewed for tube feeding, (Resident #32) and b.) obtain a physician's order to apply, monitor and care for a resident wearing a multipodus boot (a device worn to protect and correct from contractures), for 1 of 1 resident reviewed for positioning (Resident #124). 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 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 regimens as prescribed by 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.

Based on interview and record review, it was determined that the facility failed to ensure that physician face to face visits were conducted and progress notes were documented at least every 60 days. This deficient practice was identified for Resident # 90, 1 of 26 residents reviewed for the timeliness of physician progress notes and was evidenced by the following: On 10/22/20 at 10:40 AM, during the initial tour of the facility the surveyor observed Resident #90 lying in bed awake with a urinary catheter bag that was enclosed within a privacy bag on the floor to the right of the resident's bed. The surveyor reviewed the Resident Face Sheet contained within the medical record of Resident #90, which revealed that the resident was admitted to the facility in 2016 with diagnoses that included: Retention of urine, type 2 diabetes mellitus, dementia, and cerebral infarction (stroke). Review of Resident #90's quarterly Minimum Data Set (MDS) (an assessment tool) dated 09/06/2020, revealed that the resident's Brief Interview for Mental Status (BIMS) Score was three, which indicated that…

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 observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to: a.) appropriately dispose of sharps equipment in accordance with infection control guidelines b.) sanitize a multi-use equipment blood pressure cuff between resident's during the medication pass observation in accordance with infection control guidelines, and c.) properly clean and replace a soiled privacy curtain for a resident. This deficient practice was identified on 1 of 3 nursing units, (Second Floor which included six out of thirty rooms), for 1 of 1 unsampled resident during the medication pass observation, and in 1 of 26 resident's rooms, (Resident # 24). The deficient practice was evidenced by the following: 1. On 10/22/20 at 10:55 AM, the surveyor entered Resident #24's room who resided on the third floor and observed the resident lying in bed. Two staff members were observed cleaning the resident's room. The surveyor looked down at the floor by the resident's…

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.