Inspection Reports for
Alaris Health at Belgrove

Complaint #NJ184029 was substantiated. The investigation confirmed that staff failed to document call bell checks on the TAR for 3 sampled residents, despite physician orders. Interviews with the Administrator, Director of Nursing, and Registered Nurses confirmed the documentation lapses.

The facility failed to ensure staff documented and completed prescribed treatments according to physician's orders for 3 sampled residents. Multiple instances were found where call bell checks were not documented on the TAR despite physician orders requiring call bell to be within reach every shift.

Complaint # NJ184029 was substantiated based on interviews, medical record reviews, and facility documents showing deficient documentation practices for treatment administration records for three sampled residents.

The facility was found not in substantial compliance with requirements related to resident-identifiable information and medical record documentation. Specifically, staff failed to document treatment administration records (TAR) according to physician orders for three sampled residents, with call bell documentation blanks noted on multiple shifts.

The facility was found deficient in multiple areas including failure to update resident advanced directives, inadequate transfer/discharge notices, incomplete care plans, lack of emergency tracheostomy equipment and training, improper medication storage, failure to ensure cognitive ability for arbitration agreements, inadequate infection control precautions for dialysis residents, and incomplete antibiotic stewardship documentation.

The survey was complaint-driven with multiple complaint numbers listed (NJ 165484, NJ 168458, NJ 173095, NJ 173654, NJ 178621, NJ 178654, NJ 179132, NJ 179373, NJ 179453, NJ 179852).

The survey identified an Immediate Jeopardy due to failure to ensure emergency equipment was available and staff trained for a resident with a tracheostomy. Additional deficiencies included failure to update advance directives, inadequate notice for transfers and bed hold policies, incomplete baseline and comprehensive care plans, improper medication storage, and fire/life safety code violations.

The complaint investigation found substantiated deficiencies related to failure to report an injury of unknown origin and improper medication administration practices.

The facility failed to report an injury of unknown origin to the New Jersey Department of Health as required and failed to ensure medications were administered properly according to facility policy and physician orders.

Complaint # NJ00163892 involved allegations of abuse, neglect, exploitation, or mistreatment. The facility failed to report an incident involving Resident #1 to the NJDOH as required. The complaint was substantiated with findings of deficient practice.

The facility was found not in substantial compliance with regulations due to failure to report an alleged abuse incident to the New Jersey Department of Health as required, and failure to follow professional standards for medication administration, including leaving medications at a resident's bedside without ensuring ingestion.

Complaint # NJ 160113. The complaint was substantiated based on interviews, record review, and facility policy review confirming medication was not administered as ordered.

The facility failed to ensure one resident (R186) received prescribed medications on the evening of 12/08/22. Interviews with staff confirmed there were no notes explaining the missed medications, and facility policy requires documentation for missed doses.

Complaint # NJ 160113 involved failure to administer prescribed medications to one resident, resulting in potential health risks. The complaint was substantiated based on interviews, record reviews, and policy evaluation.

The facility failed to accurately code the MDS assessment for one resident, leading to potential missed care opportunities. Additionally, the facility failed to ensure one resident received prescribed medications, resulting in potential discomfort or health risks.

Complaint # NJ00160113 was substantiated with a deficiency at F760 related to medication errors. The facility failed to ensure one resident (R186) received prescribed medication, with no corrective action taken as the resident was discharged.

The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were identified related to accuracy of assessments (F641) and residents being free of significant medication errors (F760). The facility failed to accurately code Minimum Data Set (MDS) assessments and ensure prescribed medications were administered properly. Life Safety Code deficiencies were also noted in a separate survey.

The complaint investigation revealed failures in discharge notification procedures and medication administration/documentation practices. The facility did not provide required discharge notices in writing or document them in medical records. Medication administration records were inaccurately signed despite treatments and medications not being administered as ordered.

The facility failed to provide required written notices prior to resident discharges and failed to document these notices in medical records for multiple residents. Additionally, the facility failed to administer wound treatments and narcotic medications as ordered and failed to accurately document medication administration for several residents.

Complaint investigation based on complaints #NJ161781 and #NJ161918. The complaints were substantiated as the facility was found not in substantial compliance with regulatory requirements.

The facility was found not in substantial compliance with transfer and discharge requirements, failing to provide proper written notices and documentation for resident discharges and transfers. Additionally, the facility failed to administer and document medication administration accurately for certain residents. Deficient practices were identified related to discharge planning, medication administration, wound care, and narcotic medication documentation.

Complaint investigation based on complaints #NJ 146299, 146371, and 146446. The facility was found not in substantial compliance with requirements due to failure to follow physician orders and document treatments properly.

The facility failed to follow physician's orders and facility policy regarding documentation and administration of treatments for 3 of 4 residents reviewed. Missing documentation was noted for treatments and monitoring as ordered, indicating deficient practice in meeting professional standards of quality.

The investigation was complaint-driven, focusing on documentation discrepancies for Resident #58 and infection control breaches involving multiple residents. The Nurse Practitioner and facility leadership could not explain the documentation errors. The Physiatrist admitted forgetting proper PPE procedures. The facility acknowledged the issues but provided no further corrective information.

The facility failed to maintain professional nursing standards in accurately documenting physician's orders for one resident and failed to ensure proper infection prevention and control practices by medical staff and nurses for four residents, including improper PPE use and breaks in wound care technique.

Deficiencies were cited related to failure to maintain professional nursing standards in documenting physician's orders and failure to ensure proper infection prevention and control practices by staff and visiting physicians, including improper use of PPE and inadequate wound care procedures.

The facility was found to be in noncompliance due to a 6-inch diameter hole in the concrete floor of an electrical room closet on the first floor, which compromised the fire resistance and smoke integrity of the floor construction. The hole was caused by contracted vendors who failed to seal it after completing work.