Inspection Reports for
Advanced Subacute Rehabilitation Center At Sewell

Complaint #430386 and #2595402 involved allegations of staff-to-resident abuse including physical abuse of Resident 5 by Licensed Practical Nurse 1 and sexual abuse allegations against a former Maintenance Worker involving Resident 3. The facility substantiated the abuse allegation for Resident 5. Reporting to the State Survey Agency was delayed for both cases.

The facility failed to protect a resident from physical abuse by a staff member and failed to timely report allegations of abuse to the State Survey Agency, limiting regulatory oversight and potentially delaying protective interventions. The facility substantiated an allegation of abuse from a Licensed Practical Nurse to a resident and conducted staff in-services on abuse prevention and reporting.

Complaint numbers NJ171573, NJ170867, and NJ172818 were investigated. The complaints involved failure to notify the Ombudsman of hospitalization, delayed tube feeding orders, unsafe hot water temperatures causing immediate jeopardy, and inadequate fall prevention measures. The immediate jeopardy related to hot water temperatures was identified on 3/4/25 and a removal plan was accepted and verified by 3/7/25.

The facility failed to notify the State Long-Term Care Ombudsman of a resident hospitalization, delayed initiation of tube feeding orders for a resident, maintained unsafe hot water temperatures posing immediate jeopardy to residents, and failed to ensure fall prevention measures such as proper placement of floor mats and call bells for a high-risk resident.

Complaint numbers NJ171573, NJ170867, and NJ172818 were investigated. The complaints involved failure to notify the Ombudsman of hospitalization, failure to initiate timely tube feeding orders, unsafe hot water temperatures, inadequate fall prevention, and other care deficiencies. Immediate jeopardy was identified related to hot water temperatures and fall prevention.

The facility was found deficient in multiple areas including failure to notify the Ombudsman of resident hospitalization, delayed initiation of tube feeding orders, unsafe hot water temperatures posing immediate jeopardy, inadequate fall prevention measures, failure to provide humidified oxygen and proper respiratory equipment storage, medication errors exceeding 5%, and improper medication storage temperatures. The facility's Licensed Nursing Home Administrator was found responsible for failure to ensure effective systems and policies.

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.

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.

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.

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.

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 # NJ 160965 involved failure to complete fall risk assessments placing a resident at risk of repeated falls. Complaint # NJ 165790 involved failure to ensure accurate medical record documentation including SBAR completion, risking unmet care needs and falsification of documentation.

The facility failed to complete required fall risk assessments upon admission and quarterly for one resident, placing the resident at risk of repeated falls. Additionally, the facility failed to ensure accurate medical record documentation for another resident, including improper completion of SBAR communication, risking unmet care needs and falsification of documentation.

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.

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.

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.

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.

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.

The facility was found deficient in multiple areas including failure to provide appropriate colostomy care, inadequate maintenance of a clean and homelike environment, improper tube feeding administration, unsafe respiratory care practices, food safety violations, and malfunctioning essential equipment such as mechanical lifts and tube feeding pumps.

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.

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 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.

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.

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.

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 an unknown brown plastic-like substance blocking vent holes, creating a potential fire hazard.

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.