Adroit Care Rehabilitation And Nursing Center
ADROIT CARE REHABILITATION AND NURSING CENTER in RAHWAY, NJ — inspection on September 2, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
authorities.
pertinent facility documentation on 8/29/2025 and 9/02/2025, it was determined that the facility
practice was identified for 1 of 3 sampled residents (Resident #1) and was evidenced by the following: According to Resident #1's admission Record (AR), the resident was admitted to the facility with diagnoses that included but was not limited to: vascular dementia with mood disorder (commonly known as memory and thinking problems caused by poor blood flow to the brain along with mood changes). A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 8/21/2025, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15, which indicated the resident had a moderately impaired cognitive status. A review of the Progress Notes (PN) included a Nursing Note dated 8/22/2025 at 7:18 P.M., that the nurse saw Resident #1 around 3:10 P.M., well dressed with cellphone in hand. At 3:15 P.M., when the nurse returned from the end of the hallway, the resident stated they wanted to sit outside.
The nurse said okay, and documented that the physician was informed to get an out on pass order.
Unfortunately, [the resident] decided to walk away from the building while out on pass and police found [the resident] away from the building. [The resident] was accompanied by the police to the police precinct.
The Director of Nursing (DON) and the writer were contacted.
Due to a syncopal (loss of consciousness) episode at the police precinct, [the resident] had to be transferred to the emergency room for evaluation. A review of the facility's undated REPORT OF INVESTIGATION revealed under 6.
Conclusion of investigation: It was concluded that [Resident #1] who is alert and oriented BIMS 12 verbalized desire to go for a walk and sit outside for a while.
Order for Out on Pass obtained and signed by [Resident #1] .During out on pass [they] walked away.Returned to facility later in the evening, safe.
Body check done, no signs of injury.
Wander guard was placed on [Resident #1] for extra safety.
Care plan updated.During an interview on 8/29/2025 at 1:14 P.M., with the Licensed Nursing Home Administrator (LNHA) and DON, the surveyor asked if the elopement was reported to the NJDOH.
The DON stated that after reviewing the incident they determined that reporting to the NJDOH was not necessary since they had a physician's order and an out on pass signed.A review of the medical record did not include a physician's order at the time of the incident for the resident to go out on pass unescorted. A review of the facility's policy titled ACCIDENTS/INCIDENTS INVESTIGATION PROCESS dated 6/05/25, revealed under REPORTABLE EVENTS that The results of all investigations will be reported to the administration of his or her designated representative and to other officials in accordance with State law, including the State Agencies, within 5 working days of the incident with appropriate corrective action taken as a result of the investigation.NJAC 8:39-9.4(f) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
315198 09/02/2025
Adroit Care Rehabilitation and Nursing Center 1777 Lawrence Street Rahway, NJ 07065
DON stated that the Unit Manager should have updated the CP post MDS assessment when the
INVESTIGATION PROCESS dated 6/05/2025, revealed under PROCESS.Review previous interventions
and update the care plan.A review of the facility's policy titled COMPREHENSIVE CARE PLAN DATE 6/05/2025, revealed under Policy Statement: C.
Each resident's comprehensive care plan shall be reviewed and updated by the interdisciplinary team as per MDS 3.0 schedule: quarterly, annually, significant in condition and if the resident's condition warrants it. At the time of the survey the CPs were dated from the time of admission and not updated with the quarterly MDS or after the elopement occurred.NJAC 8:39-27.1 (a)
315198 09/02/2025
Adroit Care Rehabilitation and Nursing Center 1777 Lawrence Street Rahway, NJ 07065
During an interview on 9/2/2025 at 2:41 P.M., the DON stated that upon
been for as needed psychiatric and psychological consults.
The DON confirmed the PO's were not
psychiatric consult was done on 8/25/2025. A review of the facility's policy titled Out on pass dated 7/1/2025, revealed under PROCEDURE: 6.
Nursing Supervisor will notify Physician & obtain an order for Out on Pass with Responsible Party or independently if deemed appropriate. A review of the facility's policy titled DOCUMENTATION in the EMR dated 6/5/2025, revealed POLICY: It is the policy of this center to document all information related to the patients medical care in the Electronic Medical Record.NJAC 8:39- 27.1(a)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.