Gardens at Monroe Healthcare and Rehabilitation, T

In the surveyor’s words

From the most serious findings on record at Gardens at Monroe Healthcare and Rehabilitation, T, in the surveyor’s own words.

• Immediate jeopardy, widespreadF728May 4, 2023

  Based on interviews and review of pertinent facility documentation, it was determined that the facility failed to ensure a process was in place and followed to ensure untrained staff without sufficient competencies to meet the health and/or safety needs of one or more residents. [Non-permanent Nurse Aides (NAs)] were competent to provide resident care by failing to ensure: a.) NAs were full-time employees who were enrolled in a State- approved training and competency program, and b.) a system was in place to ensure all NAs received the appropriate training and deemed eligible to provide resident care, which included, but was not limited to; assisting with two person transfers, bathing and feeding dependent residents. […]

• Immediate jeopardy, widespreadF835May 4, 2023

  Based on interviews, and review of facility documents, it was determined that the facility Licensed Nursing Home Administrator (LNHA) failed to a.) ensure policies and procedures were implemented and followed to ensure all agency employed Nurse Aides (NAs) were competent and eligible to provide direct resident care for 5 of 7 NAs who worked on 4 of 4 units and provided facility wide direct resident care from 09/04/22 through 04/20/23 which placed all residents in an Immediate Jeopardy (IJ) situation and b.) follow the facility's abuse policy to ensure that all contracted NAs received criminal background check(s) prior to working at the facility and review information from licensing boards or other registries including for alleged foreign credentialed staff. […]

• No harm, potential for more than minimal, patternF880Apr 9, 2025

  Based on observations, interviews, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that a.) two Certified Nurse Aides (CNA) on 2 of 4 Units ([NAME] and [NAME]) caring for Residents #54 and #340, removed (doffed) personal protective equipment (PPE) appropriately, and b.) 1 of 3 nurses wore their facemask properly on 1 of 4 units ([NAME]) caring for Resident #2, and in accordance with the Center for Disease Control (CDC) Guidance. This deficient practice was evidenced by the following: 1. On 4/03/25 at 11:57 AM, the surveyor observed CNA #1 enter Resident #340's room who was on transmission-based precautions (TBP) [process that is implemented to prevent the spread of infections]. […]

• No harm, potential for more than minimal, patternF607May 4, 2023

  Based on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure the facility abuse policy was followed to ensure that all contracted uncertified Nurse Aides (NAs) received a.) the required criminal background check prior to working at the facility, and b.) information from licensing boards or other registries was reviewed including for alleged foreign credentialed staff. In addition, the facility failed to develop and implement a policy and procedure(s) for investigating injuries of unknown origin(s) in the facility's Abuse policy. […]

• No harm, potential for more than minimal, patternF658May 4, 2023

  Based on observation, interviews, review of medical records and other pertinent facility documents, it was determined that the facility failed to a.) ensure that there was consistent documentation of social service comprehensive assessments for 7 of 11 residents reviewed for social services (Resident's #4, #8, #10, #15, #35, #39, and #61) , and b.) clarify and accurately transcribe a physician's order for Ambien (a Sedative-Hypnotic) which resulted in a resident receiving the incorrect dose of the medication. This was identified for 1 of 25 residents (Resident #387) reviewed for medication management. The deficient practice was evidenced as follows: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. […]