Inspection Reports for Brookdale Echelon Lake

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The inspection was conducted as a complaint investigation based on Complaint # NJ 00188368 regarding medication administration and resident records at Brookdale Echelon Lake.

The facility was found not in substantial compliance with New Jersey Administrative Code standards, specifically failing to ensure medications were administered as prescribed and documentation of health care and service providers was incomplete for Resident #3. The deficiencies were evidenced by interviews, record reviews, and medication administration records showing missed doses and lack of proper communication and documentation.

Complaint # NJ 00188368 was substantiated based on evidence that Resident #3 did not receive medications as ordered for a total of 11 days and 11 doses, and documentation deficiencies were found in the resident's medical records and medication administration records.

The inspection was conducted as a complaint investigation (Complaint #NJ00175460) to determine compliance with New Jersey Administrative Code 8:36 standards for licensure of assisted living residences.

The facility was found not in substantial compliance due to failure to follow and implement its documentation policy, specifically failing to document notification of the Registered Nurse and Physician regarding a resident's hospital transfer for pain management. The deficiency was related to Resident #2 and involved incomplete medical record documentation.

Complaint #NJ00175460. The complaint investigation found that the facility failed to document RN and Physician notification for Resident #2's hospital transfer. The Regional RN and Executive Director confirmed notification occurred but was not documented.

The inspection was conducted due to complaints NJ00164461, NJ00168931, and NJ00166555 regarding sanitation and odor issues in the facility.

The facility failed to keep residents' areas free from strong odors, particularly in the main corridors and units, as evidenced by observations and interviews with staff and residents. Housekeeping staff shortages and inadequate cleaning schedules contributed to the deficient practice.

Complaint investigation for NJ00164461, NJ00168931, NJ00166555. The facility was found not in substantial compliance with sanitation standards due to strong odors and insufficient housekeeping staffing and cleaning.

This was a complaint survey conducted due to a complaint (NJ00161128) regarding failure to retain a completed Universal Transfer Form and medication administration issues.

The facility failed to retain a completed Universal Transfer Form for one resident transferred to the hospital. Additionally, the facility failed to provide prescribed pain medication to one resident for several days, did not notify the physician timely, and failed to document nurse notification of the resident's change in condition.

Complaint #: NJ00161128. The complaint involved failure to retain a Universal Transfer Form and failure to provide prescribed medication to Resident #2, resulting in ongoing pain and lack of physician notification.

The inspection was conducted as a complaint investigation based on complaints #NJ148378 and #NJ154407 regarding the facility's failure to maintain a sanitary and safe environment.

The facility was found to have black substance growth (mold) in multiple apartments and common areas, posing a serious threat to residents' health and safety. The Maintenance Director acknowledged the issue, and a Removal Plan was requested and later approved. The facility had multiple work orders related to leaks and mold. A follow-up revisit on 12/17/2022 found the facility in substantial compliance.

Complaint investigation based on complaints #NJ148378 and #NJ154407. The black substance growth was determined to be a serious threat to residents' health and safety. The facility was not in substantial compliance at the time of the complaint survey.

The inspection was conducted as a complaint investigation based on complaint number NJ00154407.

The facility was found to be in substantial compliance with New Jersey Administrative Code, Chapter 8:36, Standards for Licensure of Assisted Living Residences, Comprehensive Personal Care Homes, and Assisted Living Programs.

Complaint investigation related to complaint number NJ00154407; facility found in substantial compliance.

The inspection was conducted as a complaint investigation and a COVID-19 focused infection control survey.

The facility was found to be in substantial compliance with New Jersey Administrative Code, Chapter 8:36, Standards for Licensure of Assisted Living Residences and related infection control regulations, including CDC recommended practices for COVID-19.

Complaint number NJ148378 was investigated and the facility was found to be in substantial compliance.

Standard survey of 110 residential units to assess compliance with New Jersey Administrative Code 8:36 for licensure of assisted living residences.

The facility was found not in substantial compliance due to failure to ensure proper hand hygiene and appropriate glove use during lunch meal services on 12/02/2021 and 12/03/2021, posing potential risk to residents.