Inspection Reports for Allaire Rehab and Nursing

The facility failed to maintain sanitation in the nourishment room, evidenced by disrepair such as askew cabinet doors, stains on the ice maker grates, an empty paper towel dispenser, debris in the microwave, and peeling paint. Cleaning responsibilities were unclear and the nourishment room was only cleaned monthly, which was insufficient to maintain proper sanitation.

Complaint #2582137 involved allegations of abuse reported by local police on 08/05/2025 concerning Resident #8 and their caregiver (RR #1), and an incident involving Resident #1 and Resident #2. The facility failed to investigate the abuse allegation properly and did not separate the alleged abuser from the resident. The complaint investigation revealed failures in abuse policy implementation, investigation, and resident protection.

The facility failed to implement its abuse policy by not investigating an allegation of abuse involving Resident #8 and their caregiver, and by not protecting Resident #1 from physical and sexual abuse by Resident #2. The Licensed Nursing Home Administrator (LNHA) failed to ensure proper investigation and separation of alleged abusers, resulting in an Immediate Jeopardy situation. Additionally, the facility failed to administer medications according to policy for Resident #8.

Complaint #: NJ185442 and NJ187702. The complaints involved incomplete and inaccurate transfer forms, delayed administration of narcotic pain medication, and improper destruction of controlled medications. The complaints were substantiated based on interviews and document reviews conducted on 6/30/25, 7/1/25, and 7/2/25.

The facility failed to complete transfer forms accurately for 3 residents, failed to administer narcotic pain medication in a timely manner for 1 resident, and failed to properly destroy controlled medications for 1 resident. These deficiencies were supported by document reviews and interviews with staff including the Director of Nursing.

The complaint investigation was triggered by allegations of illegal room searches without consent, resident rights violations, and concerns about resident care including gastrostomy care and substance abuse monitoring. The investigation substantiated these complaints and identified multiple deficiencies.

The facility conducted unauthorized drug searches of all resident rooms without proper consent, violating residents' rights and causing psychosocial harm. Additional deficiencies included restricted visiting hours limiting resident access to family, incomplete advanced beneficiary notices, inadequate gastrostomy tube care, failure to address substance abuse risks and overdose prevention, unclean medication and treatment carts, and lack of timely employee 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.

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.

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 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 regarding the treatment and rights of Justice Involved Individual Resident #6, including seclusion, restraint, and denial of rights.

The facility failed to ensure that Resident #6 was afforded autonomy, dignity, and the right to participate in group activities, community dining, and communication with visitors. Resident #6 was secluded in their room, shackled by the ankles, and restricted from leaving the room except for medically necessary reasons. The facility did not implement policies to prevent physical restraints and seclusion in compliance with federal and state regulations, resulting in an Immediate Jeopardy situation.

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 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.

The complaint investigation found that the facility did not report an injury of unknown origin (abrasion to Resident #2's face from an unwitnessed fall) to the NJDOH as required. The DON and LNHA confirmed the failure to report and the facility could not provide documentation of the report. The injury was considered an allegation of abuse under facility policy.

The facility staff failed to report an unwitnessed fall resulting in an abrasion to Resident #2's face to the NJDOH. The Director of Nursing and Licensed Nursing Home Administrator acknowledged the responsibility to report such injuries but could not explain why the incident was not reported. The facility lacked documentation of the report, violating their Abuse Investigation and Reporting 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.

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 facility was found deficient in multiple areas including failure to maintain dignity in urinary catheter care, incomplete implementation of care plans for urinary catheter residents, medication administration errors, failure to act timely on consultant pharmacist recommendations, and failure to consistently monitor and document urinary catheter output.

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.

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 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 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 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.

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.

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.

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 #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.

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.

The facility failed to timely follow-up on a consultant physician's recommendation for a CT scan for one resident, and failed to maintain proper food handling and sanitation standards in the kitchen and nourishment areas, including improper storage temperatures and unclean equipment.