Inspection Reports for
Manahawkin Health and Rehabilitation Center

Complaint #2564823 involved multiple issues including unsafe room temperatures, failure to file grievances, medication administration errors, incomplete wound care, and food safety violations. The complaint was substantiated with findings of minimal harm or potential for actual harm.

The facility was found deficient in maintaining safe room temperatures in shower rooms and elevator, proper medication administration practices, failure to file and investigate grievances, incomplete wound and pressure ulcer treatments, and multiple food safety violations including improper food storage temperatures, moldy food, unsanitary kitchen conditions, and inaccurate food temperature records.

The facility was found deficient in multiple areas including resident dignity in transport, failure to issue required Medicare notices, environmental cleanliness, inaccurate resident assessments, incomplete care plans, lack of discharge summaries, inadequate respiratory care orders, insufficient RN staffing coverage, delayed response to pharmacist recommendations, menu substitutions without dietitian approval, and kitchen sanitation issues including improper dishwashing and food storage.

The complaint investigation found that the facility did not notify the physician of abnormal lab results for Resident #3 as required. The physician confirmed not being informed until reviewing lab slips on 10/24/2024, which delayed treatment. The facility policy requires prompt notification of abnormal lab results.

The facility failed to notify the physician of abnormal urinalysis results for Resident #3 received on 10/18/2024, resulting in delayed antibiotic treatment until 10/24/2024. Interviews with staff and the physician confirmed the lack of timely notification and documentation.

Complaint numbers NJ00175433 and NJ00178356 triggered the investigation. The facility was found not in substantial compliance based on these complaints.

The facility was found not in substantial compliance due to failure to notify the ordering physician of laboratory results for one resident and deficiencies in meeting minimum staffing ratios for certified nurse aides during multiple shifts.

Complaint # NJ173948 was investigated and substantiated as the facility failed to document medication administration properly for Resident #3, with blank spaces on the EMAR indicating medications were not administered or documentation was incomplete.

The facility failed to properly document medication administration for Resident #3, as evidenced by blank spaces in the EMAR on 06/06/2024 at 9:00 P.M., indicating medications were either not given or not documented. Interviews with nursing staff confirmed that blank spaces on the EMAR are unacceptable and indicate non-administration or incomplete documentation.

Complaint numbers NJ172232, NJ173948, and NJ174987 triggered the visit. The facility was found not in substantial compliance based on these complaints.

The facility was found not in substantial compliance due to failure to follow standards of clinical practice for documenting medication administration in the electronic Medication Administration Record (EMAR) for one resident, and failure to meet required staffing ratios on multiple shifts. Plans of correction were submitted with completion dates.

The complaint investigation focused on two residents (Resident #79 and Resident #167) regarding falls and accidents. Resident #167 had multiple falls related to seizure activity without appropriate neurology follow-up. Resident #79 had a physician's order for fall mats which were not consistently in place, increasing fall risk.

The facility failed to consistently follow fall prevention interventions as ordered by physicians, including failure to place fall mats for a high-risk resident, and failed to ensure a resident with multiple falls related to seizure activity received appropriate neurology specialist follow-up. These deficiencies were identified for 2 of 5 residents reviewed for falls and accidents.

The facility was found deficient in multiple areas including failure to ensure residents' dignity during dining, incomplete beneficiary notification, improper use of physical restraints, incomplete criminal background and reference checks for employees, failure to implement care plans for nail care and range of motion, inadequate fall prevention and follow-up for residents with seizure disorders, failure to maintain kitchen sanitation, failure to post menus and notify residents of menu changes, incomplete monitoring of personal refrigerators, lack of annual CNA performance evaluations, incomplete CNA in-service training, and failure to implement a comprehensive QAPI program.

The facility was found not in substantial compliance with multiple regulatory requirements including emergency preparedness, resident rights, Medicaid/Medicare coverage notices, safe environment, restraint use, care planning, ADL care, mobility, accident prevention, nurse aide training, menu compliance, food safety, infection control, and QAPI program implementation. Deficiencies were cited in these areas with corrective actions planned.

The facility was found noncompliant with multiple Life Safety Code requirements including delayed egress door features, hazardous area door enclosures, cooking facility protections, fire alarm sensitivity testing, sprinkler system maintenance, portable fire extinguisher inspections, corridor door smoke resistance, HVAC ventilation, elevator emergency communication, smoking area safety, electrical receptacle testing, emergency power system certification, power cord and extension cord usage, and oxygen cylinder storage.

Complaint#: NJ159383. The facility was not in substantial compliance based on this complaint visit.

The facility was found not in substantial compliance due to failure to develop and implement a baseline care plan for a resident, failure to transcribe a Physician's Order for treatment, and failure to consistently complete documentation of Activities of Daily Living (ADLs) care tasks. These deficiencies were identified for 1 of 3 residents reviewed.

The complaint investigation found the facility was not in compliance with 42 CFR Part 483, Subpart B, based on failure to follow professional standards of nursing practice related to medication administration for Resident #3.

The facility failed to maintain the required minimum direct care staff to resident ratios for 13 of 14 day shifts reviewed, and failed to ensure a physician's order for therapy was carried out or an alternative medication was sought when a prescribed medication was unavailable for one resident.

The facility was found deficient in infection prevention and control practices, specifically staff failing to wear required gowns when entering a resident's room under COVID-19 precautions. The facility provided re-education and in-service training to staff and implemented monthly rounds to ensure compliance.

The facility was found deficient in multiple areas including failure to keep call lights within residents' reach, inadequate cleanliness and sanitation in resident rooms and common areas, failure to follow physician orders for pain management consults, failure to remove expired medications, and unsafe food handling and kitchen sanitation practices.

The facility failed to meet the required staffing ratios for Certified Nursing Assistants (CNAs) on 49 of 57 shifts reviewed, with deficiencies noted across day, evening, and night shifts. Interviews with staff and administration confirmed awareness of the staffing shortfalls. The facility policy did not document required CNA staffing ratios.

The facility was found to be in noncompliance with several Life Safety Code requirements including improperly secured electrical outlet boxes exposing live wires, inadequate ventilation in 32 of 64 resident bathrooms, unsafe disposal of smoking refuse with over 100 cigarette butts found outside designated areas, and failure to certify that the emergency generator transfers power within the required 10-second timeframe.

Complaint # NJ 140226 was substantiated as the facility was found not in substantial compliance with medical record maintenance requirements.

The facility was found not in substantial compliance due to failure to maintain complete, accurate, and readily accessible medical records for 1 of 4 residents reviewed (Resident #3). Missing documentation included physician progress notes, nursing progress notes, and physician's order form results. The medical record was misfiled due to insufficient staff education.

The facility failed to follow appropriate infection control practices to prevent the spread of infection, including failure to post appropriate Transmission-Based Precaution signs and failure to report a positive COVID-19 case to the local health department as required by Executive Directive No. 20-013.