Dwellside Care and Rehab

In the surveyor’s words

From the most serious findings on record at Dwellside Care and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 23, 2025

  COMPLAINT #: 2599447Based on observation, interviews, review of medical records, and review of other pertinent facility documents on 9/10/2025, 9/11/2025, 9/18/2025, and 9/23/2025, it was determined that the facility failed to provide adequate supervision of a severely cognitively impaired resident (Resident #2) with a known history of exit seeking behaviors and documented history of previous attempts to elope from their unit; who eloped form the facility on 8/23/2025. The deficient practice was identified for 1 of 3 residents reviewed (Resident #2).A review of facility record revealed that on 8/23/2025 at approximately 8:15 AM, Resident #2 eloped from the facility while wearing a Wander Guard (WG; alarmed security bracelet) through an alarmed second floor elevator, down to the first… […]

• Immediate jeopardy, isolatedF600Feb 27, 2025

  NJ00176090, NJ00175919, NJ00171909, NJ00169026, NJ00165303, NJ00181236, NJ00179553, NJ00179421, NJ00175629, NJ00177976, NJ00183043, NJ00167029, NJ00165390, NJ00165211, NJ00164234, NJ00181173, NJ00183473, N00183733. Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure three residents (Resident (R)21, R22, and R24) were free from physical abuse by R20 out of a total sample of 32 residents. Due to the vulnerable nature of the nursing home population, the potential for serious injury or serious physical or psychosocial impairment from being physically abused by R20 existed, and the likeliness of R20 hitting another resident in the facility was high and required immediate action to prevent further events of physical abuse by R20. […]

• Actual harm, patternF697Apr 20, 2023

  Based on observation, interview, record review, and review of pertinent facility documentation it was determined that the facility failed to administer a physician ordered scheduled pain medication to a resident who was verbalizing pain at a level of ten (10) out of ten. This deficient practice was identified for one (1) of one residents, (Resident #35) reviewed for pain management and was evidenced by the following: Refer to F684E On 04/06/23 at 12:35 PM, Surveyor #1 observed Surveyor #2 talking to Resident #35 at the end of the hallway on the [NAME] unit. Surveyor #1 overheard the resident tell Surveyor #2 that he/she had not received any of his/her medications that day and their shoulders were in pain. […]

• Actual harm, isolatedF684Feb 27, 2025

  Based on record review and interview, the facility failed to monitor and assess a resident's skin around a cast and notify the physician timely when necrotic skin was found around the cast for one of one (Resident (R)14) reviewed for timely monitoring and assessments of 32 sampled residents. This failure resulted in harm when R14 was sent to the hospital, surgery was required, and a maggot infestation was found under the cast. Findings include: Review of R14's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed that R14 had been admitted to the facility initially on 10/14/22 with the diagnosis of dementia and diabetes mellitus. The resident passed away at the facility on 01/25/25. […]

• Actual harm, isolatedF689Oct 21, 2022

  Complaint Intake #NJ155732 Based on interviews, record review, and facility policy review, the facility failed to ensure two-person assistance was provided with transfers in accordance with a resident's care planned needs, to prevent accidents/injuries for 1 (Resident #7) of 3 sampled residents reviewed for accidents. Specifically, Resident #7, who was care planned for two-person assistance with transfers, was transferred with the assistance of only one staff member on 06/15/2022 and sustained a skin tear to the left leg. […]