Inspection Reports for
Adroit Care Rehabilitation And Nursing Center

The complaint investigation was based on allegations that the facility failed to report a resident elopement to the NJDOH and failed to implement and update the resident's care plan appropriately. The investigation found the elopement was not reported, the care plan was not updated post-incident, and physician orders for psychiatric and psychological consultations were not followed. The resident had a syncopal episode after elopement and required emergency room transfer.

The facility failed to timely report a resident elopement, did not have a documented physician's order for the resident to go out on pass at the time of the incident, failed to implement and update the resident's care plan post-elopement, and did not follow physician orders for psychiatric and psychological consultations as required.

Complaint #NJ185510 involved a family member's request for Resident #6's medical records. The request was made on 04/07/2025, but the facility delayed informing the family of the need for additional documentation until 04/21/2025, resulting in failure to provide the records within 2 days as required. The complaint was substantiated based on interviews and record reviews.

The facility failed to provide the requested medical record for Resident #6 within the required 2-day timeframe due to delayed follow-up for additional documentation needed to release the records. This deficiency was identified for 1 of 3 residents reviewed.

Complaint #NJ00176124 was substantiated based on observations, interviews, and record review showing incomplete treatment documentation for Resident #72.

The facility failed to maintain complete treatment records with staff signatures for Resident #72, as evidenced by multiple blanks in the Treatment Administration Record (TAR) for various treatments from July through October 2024. Interviews confirmed that blanks indicate unsigned records and uncertainty if treatments were performed.

Complaint # NJ00176124 regarding failure to maintain treatment records with complete staff signatures and other care deficiencies.

The facility was found deficient in multiple areas including failure to provide dignified ADL care with privacy, failure to maintain clean shower rooms, incomplete treatment records with missing staff signatures, expired vaccines stored in medication rooms, and improper disposal of personal protective equipment leading to infection control risks.

The survey included complaint investigations with complaint numbers 171414, 175944, 176124. The complaints were substantiated as evidenced by cited deficiencies related to resident care and facility environment.

The facility was found not in compliance with several regulatory requirements including Resident Rights, Safe Environment, Services Provided Meet Professional Standards, Labeling/Storage of Drugs and Biologicals, Infection Prevention and Control, and Life Safety Code requirements. Deficiencies were cited related to resident dignity, privacy, housekeeping, medication administration, infection control, and fire safety.

Complaint #NJ00155894 regarding failure to develop a comprehensive care plan for a resident with Diabetes, Epilepsy, and oxygen dependence. The complaint was substantiated based on interviews and record reviews.

The facility failed to develop and implement a complete care plan that addressed all the resident's needs, specifically omitting Diabetes, Epilepsy, and supplemental oxygen use from the care plan for Resident #104 and Resident #107. Interviews with nursing staff and administrators confirmed these omissions.

The facility was found deficient in providing a dignified dining experience, timely completion of Minimum Data Set (MDS) assessments, complete physician orders for oxygen therapy, pharmaceutical services including medication administration errors, medication refusal documentation, safe medication disposal, and secure storage of medications and narcotics. Several medication administration errors and improper medication handling practices were observed.

Complaint investigations were completed during the survey with multiple complaint numbers listed including NJ00162831, NJ00155894, NJ00165972, NJ001162775, NJ00155713, NJ00152077, NJ00152481, NJ00166081, NJ00165025, NJ00166449.

Deficiencies were cited related to resident rights, accuracy of assessments, comprehensive care plans, respiratory care, pharmacy services, medication error rates, drug labeling and storage, staffing ratios, and life safety code violations including stairway exit hardware and smoke barrier penetrations.

The facility was found to be out of compliance with infection control regulations, specifically failing to thoroughly screen all staff for COVID-19 signs and symptoms according to facility policy and CDC guidelines. Screening logs showed inadequate screening during overnight shifts.

The facility failed to ensure proper use and documentation of a feeding tube declogger device, failed to provide sufficient indication and behavior monitoring for psychoactive medication use, and failed to adhere to infection prevention protocols including hand hygiene and single-use device policies. These deficiencies posed minimal harm or potential for actual harm to residents.

The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey on multiple shifts and days during the inspection period. Interviews with staff confirmed staffing shortages and resident assignments exceeding state requirements.