Inspection Reports for
Asbury Park Nursing and Rehabilitation Center

The facility failed to maintain an effective pest control program as flies were observed in residents' rooms, and 14 out of 16 sliding doors lacked screening, increasing the risk of pest intrusion.

The complaint investigation found that Resident 1 was left in a soiled brief despite multiple observations and interviews with staff confirming the issue. The resident expressed discomfort and was not promptly assisted. Staff interviews confirmed expectations for timely brief changes were not met.

The facility failed to ensure dignity was promoted for Resident 1, who was left in a soiled brief for an extended period, causing discomfort and potential harm. Staff did not promptly change the resident's incontinent brief despite the resident's call light being on and expressed discomfort.

The complaint investigation substantiated that Resident 1 slapped Resident 2, Resident 3 punched Resident 4 in the thigh, and Resident 3 expressed verbal slurs to Resident 6. The incidents were confirmed through interviews, observations, and record reviews.

The facility failed to protect 3 of 6 sampled residents from abuse by peer residents, including physical and verbal abuse incidents involving Residents 1, 2, 3, 4, and 6, resulting in minimal harm or potential for actual harm.

The facility had multiple deficiencies including failure to obtain informed consents from authorized representatives, failure to protect resident health information confidentiality, failure to notify residents or representatives of bed hold rights, medication errors including missed psychotropic medications, inadequate foot care, failure to ensure dialysis care coordination, medication storage and accountability issues, failure to follow psychotropic medication guidelines, medication administration errors, dietary and food safety deficiencies, lack of dialysis service contracts, infection control lapses, call light accessibility issues, and maintenance problems affecting safety and sanitation.

The complaint investigation revealed Resident 1 left the facility without an approved LOA, was taken home by a friend unknown to staff, and was not located by staff until he returned. The incident was substantiated as a failure in supervision and adherence to LOA policies.

The facility failed to identify that Resident 1 left the nursing home with an unidentified person without an approved LOA, placing the resident at risk of harm. Multiple interviews and record reviews confirmed the resident was cognitively intact but dependent on assistance for mobility and transfers. Staff and family members were unaware or misinformed about the resident's whereabouts until he returned on his own.

The facility failed to maintain an effective Infection Prevention and Control Program by not ensuring staff wore required PPE while providing catheter care and by not having PPE readily available outside the rooms of residents on ESP, increasing the risk of cross-contamination and potential infections.

The complaint investigation found substantiated issues with call light response delays and inadequate assistance with toileting and personal care, causing residents to feel anxious, frustrated, embarrassed, and helpless.

The facility failed to respond timely to residents' call lights, resulting in residents experiencing discomfort, embarrassment, and unmet needs. Multiple observations and interviews confirmed staff ignored or delayed responding to calls for assistance, violating residents' rights to dignity and timely care.

The complaint investigation found that the facility did not provide documented evidence that a summary of the investigation was submitted within 5 working days as required. The Director of Nursing later validated that a 5-day follow-up investigation summary was submitted within the required timeframe.

The facility failed to report the results of the 5-day investigation within the required timeframe for two residents when Resident 1 scratched Resident 2, which decreased the facility's potential to provide appropriate corrective actions to safeguard resident health and safety.

The facility failed to maintain clear evacuation routes, which were cluttered with carts, bedside commodes, linen bins, and garbage bins, causing Resident 4 to feel unsafe and increasing the risk of delayed evacuation in an emergency. The Director of Nursing and Administrator acknowledged these issues and the need to keep evacuation routes free of obstructions.

The facility failed to implement a physician's order to change a resident's diet consistency, failed to provide adequate access to water for hydration, and failed to maintain proper respiratory infection control by not changing oxygen tubing as ordered. These deficiencies posed minimal harm or potential for actual harm to the resident.

The facility was found deficient in multiple areas including failure to treat a resident with dignity when a staff member cut her hair against her wishes, failure to follow physician's orders for catheter care resulting in multiple UTIs and hospitalization, failure to prevent significant unplanned weight loss due to inadequate intervention on meal refusals, and failure to ensure proper infection prevention practices during a COVID-19 outbreak with staff improperly wearing PPE.

The facility failed to timely address a resident's concern regarding missing prescription glasses and failed to ensure a resident with a milk allergy was not served dairy products. Interviews and record reviews confirmed lapses in communication and meal tray accuracy.

The facility failed to adhere to professional standards for one resident by ordering baclofen without considering the resident's kidney failure, posing a potential risk of drug toxicity. The pharmacist consultant did not identify the order during medication reviews, and the medication was administered for several days despite contraindications.

The facility failed to provide adequate grooming and personal hygiene services to Resident 1, who did not receive a shower during her stay, resulting in a hair knot. Documentation showed Resident 1 only received bed/towel baths and had multiple refusals documented. Interviews confirmed the failure to provide scheduled showers and proper documentation.

The facility failed to provide appropriate urinary catheter care for one resident, resulting in delayed urology referral and potential for urinary tract infection. Additionally, the facility did not ensure proper nutritional status for the same resident, with significant weight loss and lack of timely notification to medical providers.

The facility failed to provide needed care and services including bathing for a resident, failed to reorder anticoagulant medication after surgery cancellation leading to a deep vein thrombosis and hospitalization, maintained inaccurate medical records documenting treatments not performed, and failed to implement proper infection control practices during resident transport while on Covid quarantine.

The complaint was substantiated as the CNA did not honor the resident's request, resulting in the resident feeling disrespected. The Director of Staff Development handled the complaint by asking the CNA to apologize, but the resident was not satisfied with the resolution.

The facility failed to ensure that Resident 1 was treated with dignity and respect when CNA 1 did not honor the resident's request to place the bedside commode in the bathroom after each use. The issue was addressed informally by the Director of Staff Development who asked the CNA to apologize, but the resident was not satisfied with the handling of the complaint.

The facility was found deficient in multiple areas including failure to ensure call light accessibility for a resident, inconsistent application of prescribed treatments such as passive range of motion and splinting, inadequate continence care, improper medication emergency kit documentation and security, food safety violations including lack of air gap on sink and improper storage, and failure to follow infection control practices during wound care.