Ashbrook Care & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Ashbrook Care & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 9, 2025

  Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to protect Resident #43, as well as all residents from abuse, when on 5/7/25, an alert and oriented resident (Resident #43) with a history of being abused, informed the surveyor that they reported an allegation of sexual abuse to staff that was not investigated. This deficient practice occurred for 1 of 4 residents reviewed for abuse (Resident #43). On 5/6/25, Resident #43 informed Surveyor #1 that they [the residents] were having a problem with me because I am gay, some residents were afraid of me and some of the nurses made me touch them, I have not seen them. […]

• Immediate jeopardy, isolatedF609May 9, 2025

  Refer to F 600 and F 610 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of sexual abuse after Resident #43 reported to the Registered Nurse/Unit Manager (RN/UM #1) that sometime at the end of December 2024 or January 2025, their buttocks was inappropriately touched by two female staff members. This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident #43). On 5/6/25, Resident #43 informed Surveyor #1 that they [the residents] were having a problem with me because I am gay, some residents were afraid of me and some of the nurses made me touch them, I have not seen them. […]

• Immediate jeopardy, isolatedF610May 9, 2025

  Refer to F 600 & F 609 Based on observation, interview, record review, and review of pertinent documentation, it was determined that the facility failed to initiate and complete a thorough investigation for an allegation of sexual abuse, after a resident (Resident #43) informed staff that two female staff members inappropriately touched their buttocks. This deficient practice was identified for 1 of 4 residents reviewed for abuse (Resident #43). On 5/6/25, Resident #43 informed Surveyor #1 that they [the residents] were having a problem with me because I am gay, some residents were afraid of me and some of the nurses made me touch them, I have not seen them. […]

• Immediate jeopardy, isolatedF835May 9, 2025

  Refer F 600, F 609, F 610 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by a.) ensuring all residents were protected from abuse; b.) ensuring an allegation of sexual abuse was thoroughly investigated; and c.) reporting an allegation of sexual abuse to the New Jersey Department of Health (NJDOH). […]

• No harm, potential for more than minimal, widespreadF584May 9, 2025

  Complaint # NJ 173967 REPEAT DEFICIENCY Based on observation and interview, it was determined that the facility failed to ensure the environment and common areas were maintained in a clean, homelike and sanitary manner. The deficient practice occurred on 2 of 2 resident units (North and South) and in the main dining room/activity room and was evidenced by the following: On 5/4/25 at 7:15 AM, the surveyor entered the main dining room and observed the wall air condition unit was missing molding around it, there were visible rips in the wall paper in several areas, the ceiling was cracked, the vents in the dining room were soiled with debris, the window air conditioning unit had debris inside the vent, and several chairs were visibly worn through the paint and at 7:19 AM, the surveyor… […]