Inspection Reports for Advanced Subacute Rehabilitation Center At Sewell
685 Salina Road, NJ, 08080
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their health information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for the notice |
Inspection Report
Routine
Census: 130
Capacity: 139
Deficiencies: 9
Mar 7, 2025
Visit Reason
A Recertification/LSC Survey was conducted from 3/3/25 through 3/7/25 to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities.
Findings
The facility was found not in compliance with multiple requirements including failure to maintain safe hot water temperatures posing immediate jeopardy, failure to notify the Office of the State Long-Term Care Ombudsman of a resident hospitalization, failure to initiate physician's orders timely, medication errors exceeding 5%, and deficiencies in life safety code related to fire safety and emergency preparedness.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to ensure hot water temperatures were maintained at safe levels to protect residents from serious injury, with temperatures between 138 and 140 degrees Fahrenheit. | Immediate Jeopardy |
| Facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident hospitalization. | — |
| Facility failed to initiate physician's orders in a timely manner for residents. | — |
| Medication error rates exceeded 5%, with a 7% error rate observed during medication pass. | — |
| Facility failed to maintain safe and functional fire safety systems including fire doors, smoke barrier doors, and fire extinguishers. | — |
| Facility failed to conduct required emergency preparedness evacuation drills and maintain documentation. | — |
| Facility failed to maintain safe storage and handling of oxygen cylinders and compressed gases. | — |
| Facility failed to maintain safe food storage temperatures and proper labeling of food items. | — |
| Facility failed to maintain required staffing levels for Certified Nursing Assistants (CNAs) on multiple shifts. | — |
Report Facts
Census: 130
Total Capacity: 139
Medication Error Rate: 7
Medication Error Rate Threshold: 5
Hot Water Temperature: 138
Hot Water Temperature: 140
Deficiency Completion Date: Apr 21, 2025
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 1
Nov 14, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint numbers (NJ00177966, NJ00178821, NJ00178897, NJ00178929, NJ00178990) to assess compliance with federal and state regulations.
Findings
The facility was found to be in substantial compliance with federal requirements but was not in compliance with New Jersey state licensure standards due to failure to maintain required minimum staff-to-resident ratios on 22 of 36 day shifts during the complaint period. No residents were directly affected by the staffing deficiencies.
Complaint Details
The complaint investigation was based on multiple complaint numbers. The facility failed to meet minimum staffing requirements for Certified Nurse Aides (CNAs) on 22 of 36 day shifts between 09/29/24 and 11/09/24. The facility was found to be in substantial compliance with federal requirements but not with state staffing regulations. No residents were affected by the deficient practice.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 22 of 36 day shifts. |
Report Facts
Census: 137
Day shifts with deficient CNA staffing: 22
Sample Size: 7
Required CNAs on specific days: 17
Actual CNAs on specific days: 13
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 1
Jun 18, 2024
Visit Reason
The inspection was conducted based on multiple complaints (NJ00171817, NJ00172257, NJ00173655, NJ00173803) to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found to be in substantial compliance with federal requirements but was not in compliance with New Jersey state staffing regulations, specifically failing to meet minimum Certified Nursing Assistant (CNA) staffing ratios on multiple day shifts during the review periods.
Complaint Details
The visit was complaint-related with multiple complaint numbers cited. The facility was found to be in substantial compliance with federal requirements but deficient in state staffing requirements. No residents were identified as affected by the deficient staffing practice.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 32 of 42 day shifts. |
Report Facts
CNA staffing deficiency days: 32
CNA staffing deficiency days: 6
Census: 126
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 3
Dec 29, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to multiple complaint numbers listed, with survey dates from 12/27/2023 to 12/29/2023.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on the complaint visit. Deficiencies included failure to complete fall risk assessments timely for one resident, inaccurate medical record documentation for another resident, and failure to maintain required minimum staffing ratios on multiple shifts.
Complaint Details
The complaint investigation involved multiple complaint numbers including NJ00153345, NJ00159409, NJ00160088, NJ00160965, NJ00162255, NJ00164006, NJ00165103, NJ00165790, NJ00166779, NJ00167680, NJ00169771, NJ00169757, NJ00169869. The facility was found not in substantial compliance based on these complaints.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure a fall risk assessment was completed upon admission and quarterly for one of three residents reviewed for falls, placing the resident at risk of diminished quality of life. | SS=D |
| Failure to ensure the medical record was accurate and that SBAR documentation was completed by the staff person who witnessed the event for one resident, risking unmet care needs and falsification of documentation. | SS=D |
| Failure to maintain required minimum staff-to-resident ratios as mandated by the state of New Jersey for 9 of 45 day shifts and 1 of 7 evening shifts, potentially affecting all residents. | — |
Report Facts
Survey Census: 123
Sample Size: 15
Deficient staffing shifts: 10
Staffing ratios: 8
Staffing ratios: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager 2 | Unit Manager | Named in relation to failure to complete fall risk assessments and improper SBAR documentation |
| Director of Nursing | Director of Nursing (DON) | Named in relation to oversight of fall risk assessments and SBAR documentation |
Inspection Report
Census: 101
Capacity: 147
Deficiencies: 5
May 15, 2023
Visit Reason
The facility requested to increase their total licensed bed count by eight beds from 139 to 147 and underwent a new construction project survey including inspection of the new 500 wing and related areas.
Findings
The facility was found noncompliant with New Jersey licensure standards and Medicare/Medicaid participation requirements, citing deficiencies in staffing ratios, emergency lighting, fire alarm system maintenance, sprinkler system installation, and essential electrical system requirements.
Severity Breakdown
SS=C: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain required minimum direct care staff-to-resident ratios for 4 out of 42 shifts reviewed. | — |
| Failed to provide battery back-up emergency lighting above the emergency generator transfer switch in the basement electrical room. | SS=C |
| Fire alarm panel behind the new 500-wing nurses station did not indicate normal mode and was not resetting. | SS=C |
| Sprinkler system lacked coverage in HVAC closet and skylights in the 500-wing dining room area. | SS=C |
| Failed to install a remote manual stop station for the outside generator providing emergency power to the new 500-wing. | SS=C |
Report Facts
Shifts reviewed: 42
Shifts deficient: 4
Current census: 101
Licensed capacity: 147
Beds requested to add: 8
New beds in 500 wing: 25
Generator capacity: 750
Skylights without sprinkler coverage: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding staffing and nurse staffing report | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding staffing and confirmed emergency lighting and fire alarm findings | |
| Maintenance Director (MD) | Confirmed emergency lighting, fire alarm, sprinkler, and electrical system deficiencies | |
| Regional Plant Operations Director (RPOD) | Present during observations and interviews regarding deficiencies | |
| Regional Facilities Manager (RFM) | Present during sprinkler system observations |
Inspection Report
Annual Inspection
Census: 104
Deficiencies: 7
Feb 17, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to resident rights and dignity, safe and clean environment, colostomy care, enteral nutrition administration, respiratory care, food safety, and maintenance of essential equipment including mechanical lifts and feeding pumps.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to provide a resident with respect and dignity as evidenced by resident #159 with leaking ostomy bag and inadequate supplies. | SS=D |
| Facility failed to provide a clean, comfortable, homelike environment for residents #99 and #158 with cracked floors, stained poles, and unclean rooms. | SS=D |
| Facility failed to provide appropriate care for resident #159 with a new ostomy due to unavailability of well fitted supplies. | SS=D |
| Facility failed to administer enteral nutrition per physician's order for residents #99 and #158; formula not properly labeled, dated, or administered. | SS=E |
| Facility failed to appropriately follow physician orders for respiratory care and store respiratory equipment in a manner to prevent infection for residents #99 and #158. | SS=D |
| Facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner; missing temperature logs and uncovered slicer with debris. | SS=E |
| Facility failed to maintain mechanical lifts with scales in accurate operating condition and failed to provide functional feeding pump for resident nutrition. | SS=D |
Report Facts
Census: 104
Deficiency count: 7
Weight deviation threshold: 10
Feeding formula volume: 300
Feeding formula flow rate: 60
Mechanical lift weight: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN#1 | Licensed Practical Nurse | Involved in care and interview regarding ostomy bag and enteral nutrition for Resident #159 and Resident #99 |
| LPN#2 | Licensed Practical Nurse | Interviewed about enteral nutrition and resident care |
| LPN/UM | Licensed Practical Nurse/Unit Manager | Interviewed about ostomy care, enteral nutrition, and respiratory care |
| CNA#1 | Certified Nursing Assistant | Interviewed about resident care and mechanical lift use for Resident #81 |
| DON | Director of Nursing | Interviewed about resident care, equipment maintenance, and staff education |
| RD | Registered Dietitian | Interviewed about nutritional care and enteral feeding orders |
| DODS | Director of Dining Services | Interviewed about food safety and kitchen sanitation |
| MD | Maintenance Director | Interviewed about equipment maintenance and mechanical lift issues |
| Administrator | Facility Administrator | Interviewed about equipment maintenance and facility policies |
Inspection Report
Life Safety
Census: 103
Capacity: 122
Deficiencies: 8
Feb 14, 2023
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health on 02/14/23 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including egress door signage, exit signage, fire alarm system testing, sprinkler system maintenance, portable fire extinguisher availability, corridor door latching, smoking area safety, and essential electrical system requirements related to the emergency generator.
Severity Breakdown
SS=F: 5
SS=E: 2
SS=D: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Exit doors lacked signage with letters at least 1 inch high and 1/8 inch stroke width as required for 15-second delayed egress doors. | SS=F |
| An exit door in Therapy was not marked with an EXIT sign as required. | SS=E |
| Fire alarm system was not tested semi-annually and smoke detection sensitivity test was not completed for all detectors. | SS=F |
| Deficiencies found during sprinkler system inspection were not corrected, specifically a faulty accelerator. | SS=F |
| Kitchen lacked required Class A and Class B or C portable fire extinguishers. | SS=F |
| Corridor doors failed to latch properly into the frame, potentially affecting 62 residents. | SS=E |
| Smoking area lacked an ashtray of noncombustible material and a metal container with self-closing cover for ashtray disposal. | SS=D |
| Emergency generator lacked a remote manual stop station to prevent inadvertent operation. | SS=F |
Report Facts
Residents affected by egress door signage deficiency: 103
Residents affected by missing exit sign: 10
Photo electric smoke detectors: 242
Residents affected by fire alarm system deficiency: 103
Residents affected by sprinkler system deficiency: 103
Residents affected by fire extinguisher deficiency: 103
Residents affected by corridor door latching deficiency: 62
Residents affected by smoking area deficiency: 1
Residents affected by emergency generator deficiency: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings including fire alarm system testing, sprinkler system maintenance, fire extinguisher availability, corridor door latching, smoking area safety, and emergency generator deficiencies. | |
| Administrator | Interviewed regarding exit signage deficiency and involved in monitoring corrective actions. |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 1
Mar 9, 2022
Visit Reason
The inspection was conducted based on complaint numbers NJ150849 and NJ149823 to investigate compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility failed to ensure family notification of a medication change for one resident, as documentation of such notification was missing despite verbal orders and medication administration. The facility implemented corrective actions including staff re-education and monitoring procedures to ensure family notification for medication changes.
Complaint Details
Complaint Intake #NJ149823 found that the facility failed to document family notification of a medication change for one resident. Interviews with nursing staff and the Director of Nursing confirmed the lack of documentation despite verbal notification claims.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure family notification of a medication change for one resident. | SS=D |
Report Facts
Census: 106
Sample Size: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Nurse who entered medication orders and acknowledged verbal notification to family without documentation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for family notification of medication changes |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 3
Oct 23, 2021
Visit Reason
Complaint survey based on allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, and a COVID-19 Focused Infection Control Survey conducted by the New Jersey Department of Health.
Findings
The facility failed to report an injury of unknown origin for Resident #1 to the NJ Department of Health, failed to ensure dietary staff performed proper hand hygiene and maintain dishwasher temperature, and failed to implement an effective infection prevention and control program including proper mask use, hand hygiene, and housekeeping practices during the COVID-19 pandemic.
Complaint Details
Complaint Intake #NJ148524 involved failure to report an injury of unknown origin for Resident #1. The facility was found not in compliance with infection control regulations during a COVID-19 Focused Infection Control Survey.
Severity Breakdown
SS=D: 1
SS=F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report an injury of unknown origin involving Resident #1 to the NJ Department of Health. | SS=D |
| Failure to ensure dietary staff performed hand hygiene between tasks and failure to maintain dishwasher rinse temperature at manufacturer's recommended level. | SS=F |
| Failure to implement an infection prevention and control program including proper mask use, hand hygiene, and housekeeping practices, resulting in potential transmission of COVID-19 and other infections. | SS=F |
Report Facts
Census: 108
Sample Size: 8
Dishwasher rinse temperature: 170
Dishwasher rinse temperature recommended: 180
Dishwasher wash temperature recommended: 150
Contact time for disinfectant: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Called to assess Resident #1's injury and arranged hospital transfer. |
| CNA #2 | Certified Nurse Aide | Assigned aide to Resident #1, no prior disciplinary actions found. |
| LPN #1 | Licensed Practical Nurse | Called RN #2 to assess Resident #1. |
| Housekeeper #1 | Observed failing to perform hand hygiene and proper cleaning procedures. | |
| Dietary Aide #1 | Observed failing to perform hand hygiene between tasks. | |
| Dietary Aide #2 | Observed failing to perform glove changes and hand hygiene. | |
| Infection Control Preventionist | Provided infection control training and oversight. | |
| Director of Nursing | Oversaw infection control and investigation of Resident #1's injury. | |
| Environmental Service Director | Supervised housekeeping and cleaning procedures. |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Sep 10, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ145586, NJ146682, NJ145216, NJ147978, and NJ147792.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ145586, NJ146682, NJ145216, NJ147978, and NJ147792 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 18
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 0
Aug 13, 2021
Visit Reason
The inspection visit was conducted in response to a complaint identified as NJ147272.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint NJ147272 was investigated and the facility was found compliant with no deficiencies cited.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
Jun 11, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ141981, NJ142822, NJ142903, NJ143480, and NJ143673.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
The survey was complaint-driven with multiple complaints referenced. The facility was found compliant with no deficiencies cited.
Report Facts
Sample Size: 10
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
Dec 30, 2020
Visit Reason
The inspection was conducted as a complaint investigation based on complaint #NJ142019.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint #NJ142019 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Annual Inspection
Census: 89
Deficiencies: 1
Nov 30, 2020
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility failed to maintain 4 of 4 commercial clothes dryer drums in a safe operating condition, with 3 dryers out of order and all drums coated with a brown plastic-like substance blocking vent holes, creating a fire risk.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain 4 of 4 commercial clothes dryer drums in safe operating condition; dryers #1, #2, and #4 were out of order with vent holes blocked by a brown plastic-like substance and clothes labels. | SS=E |
Report Facts
Census: 89
Sample size: 27
Number of commercial dryers: 4
Number of dryers out of order: 3
Number of dryers cleaned: 3
Inspection frequency for QA: 3
Duration of QA monitoring: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observation and interview confirming dryer conditions | |
| Laundry Director | Present during observation and interview confirming dryer conditions and re-educated laundry staff | |
| Director of Environmental Services | Re-educated laundry staff, responsible for cleaning oversight and quality assurance monitoring |
Inspection Report
Routine
Census: 89
Deficiencies: 0
Nov 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 3
Inspection Report
Life Safety
Deficiencies: 1
Nov 24, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code requirements, specifically focusing on the fire alarm system's testing and maintenance in accordance with NFPA 70 and NFPA 72 standards.
Findings
The facility failed to maintain the building's fire alarm system in normal operating condition, with the main fire alarm panel observed in trouble mode due to issues related to ongoing construction. The fire alarm vendor was notified, and corrective actions including reprogramming and daily monitoring were implemented.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain the building's fire alarm system in normal operating condition in accordance with NFPA 70/72, with the fire alarm panel in trouble mode. | SS=D |
Report Facts
Date of survey completion: Nov 30, 2020
Date of fire alarm system repair: Nov 27, 2020
Date of fire alarm vendor document: Sep 3, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director interviewed regarding fire alarm panel trouble mode and corrective actions |
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