Inspection Reports for Allaire Rehab and Nursing

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A project survey was conducted for occupancy approval for the 3rd floor Phase 1 project at Allaire Rehab and Nursing.

The facility was surveyed for compliance with NJAC 8:39 and NFPA 101:2012 Edition and there were no deficient practices identified at the time.

A Recertification/LSC Survey was conducted from 10/29/24 through 11/01/24 to determine compliance with 43 CFR Part 483 requirements for Long Term Care Facilities, triggered by multiple complaints.

The facility was found to have an Immediate Jeopardy (IJ) related to searching all 136 residents' rooms without obtaining informed consent, violating residents' rights to dignity and privacy. Additional deficiencies included inadequate staffing, failure to ensure resident safety, and issues with medication cart cleanliness and performance reviews.

The visit was complaint-driven, with multiple NJ complaint numbers listed. The Immediate Jeopardy was substantiated related to unauthorized room searches by a drug-sniffing canine and staff without resident consent.

Complaint survey conducted from 08/13/2024 through 08/19/2024 to determine compliance with 42 CFR Part 483 for Long Term Care facilities, triggered by complaint #NJ00176157.

The facility was found not in substantial compliance with federal requirements, with an Immediate Jeopardy (IJ) situation identified related to Resident #6 being denied autonomy, dignity, and rights including participation in group activities, community dining, communication with visitors, and freedom to leave their room. The facility also failed to ensure proper admission agreements, freedom from involuntary seclusion, and compliance with resident rights policies. Staffing ratios were below state minimum requirements on several day shifts.

Complaint #NJ00176157 involved allegations that Resident #6 was denied autonomy, dignity, and rights including participation in group activities, community dining, communication with visitors, and freedom to leave their room. The complaint also included failure to obtain admission agreements and failure to comply with resident rights policies. Immediate Jeopardy was identified and removed after corrective actions.

The inspection was conducted in response to complaint NJ172396 to investigate compliance with staffing ratios and other regulatory requirements.

The facility was found to be not in compliance with New Jersey Administrative Code 8:39 regarding staffing ratios, specifically failing to meet the minimum Certified Nurse Aide (CNA) staffing requirements on one of 14 day shifts reviewed. The facility was substantially compliant overall based on this complaint visit.

Complaint #: NJ172396. The facility failed to meet minimum staffing ratios as required by New Jersey law, potentially affecting all residents. The complaint was substantiated with findings of deficient CNA staffing on one day shift.

The inspection was conducted as a complaint survey to investigate allegations of abuse, neglect, exploitation, or mistreatment at the facility.

The facility was found not in substantial compliance due to failure to report an injury of unknown origin involving Resident #2 to the New Jersey Department of Health as required by state law and facility policy.

The complaint investigation found that the facility staff failed to report an injury of unknown origin for Resident #2 to the NJDOH as required. The injury was unwitnessed, and the facility did not provide documentation of reporting. The Director of Nursing and Licensed Nursing Home Administrator acknowledged the failure to report despite policy requirements.

A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

Deficiencies were cited related to resident rights, care plan implementation, medication administration, urinary catheter care, drug regimen review, medication error rates, staffing ratios, and life safety code compliance including exit signage, hazardous area enclosures, sprinkler system installation, portable fire extinguishers, corridor doors, and electrical systems.

A Life Safety Code Survey was conducted by the New Jersey Department of Health on 11/28/22 and 11/29/22 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for Allaire Rehabilitation and Nursing Center.

The facility was found noncompliant in multiple areas including exit signage, hazardous area enclosures, sprinkler system installation, portable fire extinguisher maintenance, corridor door smoke resistance, and electrical outlet GFCI protection. Deficiencies were confirmed by facility management and corrective actions were planned or initiated.

The survey was conducted as a Life Safety Code Survey related to a new construction and renovation project (Phase 2) involving four renovated resident rooms at Allaire Rehab & Nursing.

The facility was found to be in noncompliance with fire safety requirements, specifically regarding the fire alarm system which showed a 'Trouble in System' alert due to battery trouble. The system was not maintained in accordance with NFPA 70 and NFPA 72 requirements, potentially affecting all residents. The facility's vendor was scheduled to repair the system promptly.

The survey was conducted as part of a New Construction and Renovation Project, specifically Phase 2 involving four renovated resident rooms (240, 241, 242, and 243). A Life Safety Code Survey was performed to assess compliance with fire safety regulations.

The facility was found to be in noncompliance with fire alarm system maintenance requirements per NFPA 70 and NFPA 72. The fire alarm annunciator panels indicated a 'Trouble in System' due to battery trouble, which had the potential to affect all residents. The facility's fire alarm vendor was scheduled to repair the issue promptly.

The inspection was conducted as a complaint survey to investigate allegations related to staffing ratios and compliance with state staffing requirements.

The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by New Jersey state law, with deficiencies noted in CNA staffing on 10 of 14 day shifts and total staff shortages on several evening and overnight shifts.

The facility was found not in compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey. Staffing deficiencies were substantiated with specific shortages documented on multiple shifts.

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.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.

The inspection was conducted as a complaint survey based on multiple complaint intakes regarding cleanliness and grievance handling at the facility.

The facility failed to maintain a safe, clean, and homelike environment as evidenced by unclean resident rooms, dirty treatment carts, and inadequate housekeeping practices. Additionally, the facility failed to properly log and investigate grievances, and the grievance policy lacked required elements for prompt resolution and documentation.

Complaint Intakes: NJ146816, NJ146569, NJ146504, NJ146015, NJ145950, NJ144651, NJ143729, NJ141607, and NJ141575. The complaint investigation found the facility was not in compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on issues of cleanliness and grievance handling.

Complaint investigation #NJ 142207 was conducted due to concerns about a resident who left the facility unattended, was struck by a car, and the facility's failure to supervise, monitor, and ensure resident safety.

The facility failed to supervise a resident with a history of wandering who left unattended and was injured in a traffic accident. The facility also failed to report the incident timely, conduct a thorough investigation, follow physician orders restricting the resident's pass privileges, and maintain adequate staffing levels. Policies on abuse reporting, care planning, and resident supervision were not properly followed, placing residents at risk.

Complaint #NJ 142207 involved a resident who left the facility unattended, was struck by a car, and sustained injuries. The facility failed to supervise the resident, report the incident timely, investigate thoroughly, follow physician orders, and maintain adequate staffing. The resident had a history of wandering and elopement behaviors. The complaint was substantiated with Immediate Jeopardy identified from 12/19/20 to 01/08/21.

Initial inspection for licensure of renovated long term care facilities.

No deficiencies were noted during the inspection of the renovated areas including the rehab therapy gym, 2nd floor annex unit, ground floor lobby with bistro and visitor bathrooms, two shower rooms on the 2nd floor, and a bariatric suite (room 136).