Inspection Reports for
Alliance Care Rehabilitation And Nursing Center
155 40th Street, Irvington, NJ, 07111
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
10.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
106% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
67% occupied
Based on a October 2024 inspection.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of the New Jersey Department of Health and Senior Services, including how their medical 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 regarding their health information, and the department's legal duties and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 17, 2024
Visit Reason
The inspection was a routine regulatory survey of Alliance Care Rehabilitation and Nursing Center to assess compliance with Medicare and Medicaid requirements, including review of resident care, medication administration, abuse prevention, infection control, and other regulatory standards.
Findings
The facility was found deficient in multiple areas including failure to provide Medicare Advanced Beneficiary Notices, inadequate prevention and investigation of resident-to-resident abuse, improper positioning of a resident during tube feeding, medication administration errors including unavailable medications and documentation issues, and failure to follow enhanced barrier precautions for infection control.
Deficiencies (7)
Failure to provide CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to residents at the end of their Medicare covered stay.
Failure to prevent resident-to-resident abuse when Resident R54 pushed and hit R411.
Failure to thoroughly investigate resident-to-resident abuse incidents for residents R54, R210, and R411.
Failure to ensure resident R91 was positioned with head elevated 30-45 degrees during tube feeding, risking aspiration.
Failure to have medications available as ordered, document reasons for missed medications, and maintain accessible records for controlled medications for residents R141, R261, and R366.
Medication error rate of 12% observed during medication administration, including incorrect dosing and documentation errors for resident R366.
Failure to utilize proper personal protective equipment (PPE) including gowns and gloves for enhanced barrier precautions and failure to perform proper hand hygiene for resident R91 with a feeding tube.
Report Facts
Medication error rate: 12
Medication administration opportunities observed: 25
Medication errors observed: 3
Residents reviewed for medication administration: 7
Residents reviewed for tube feeding: 31
Residents reviewed for abuse: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Confirmed failure to issue CMS Form 10055 for Medicare non-coverage notices. | |
| Director of Nursing | DON | Provided information on abuse investigations, medication administration expectations, and infection control practices. |
| Charge Nurse 3 | CN3 | Observed administering medications and reported medication availability issues. |
| Licensed Practical Nurse Supervisor | LPN Supervisor | Provided information on medication administration policies and medication availability. |
| Certified Nursing Assistant 6 | CNA6 | Observed providing care to resident R91 including tube feeding and hygiene; reported concerns about head of bed elevation. |
| Charge Nurse 4 | CN4 | Observed performing tube feeding care without gown use. |
| Infection Preventionist | IP | Provided information on enhanced barrier precautions and PPE use. |
| Regional Nurse | Provided information on abuse investigation files. |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 201
Deficiencies: 11
Date: Oct 17, 2024
Visit Reason
A Recertification and Complaint Survey was conducted due to multiple complaint investigations and recertification requirements.
Complaint Details
The visit was complaint-related with multiple complaint numbers investigated including NJ162228, NJ162935, NJ167657, NJ168466, NJ172337, NJ173560, NJ175028, NJ175594, NJ176777, NJ176784, NJ176900, and NJ178259. The facility was found not in substantial compliance based on these complaints.
Findings
The facility was found not in substantial compliance with federal regulations including failures in Medicaid/Medicare coverage notices, abuse prevention, investigation of alleged violations, tube feeding management, pharmacy services, medication error rates, infection prevention and control, and life safety code compliance.
Deficiencies (11)
Failed to provide Medicaid/Medicare Coverage/Liability Notice (CMS Form 10055) to residents at the anticipated end of their Medicare covered stay.
Failed to prevent abuse and neglect between residents, and failed to ensure proper investigation of abuse allegations.
Failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for three residents.
Failed to ensure a resident was properly positioned during enteral feeding to prevent aspiration pneumonia.
Failed to have medications available as ordered, document reasons for unavailable medications, and maintain accessible records for medication administration for three residents.
Medication error rate exceeded 5 percent during observation of medication administration with three errors in twenty-five opportunities.
Failed to utilize proper personal protective equipment and perform proper hand hygiene for a resident requiring enhanced barrier precautions.
Failed to maintain delayed egress locking system to release door after 15 seconds of pressure, affecting staff and residents.
Failed to maintain exit passageway doors with required fire exit hardware, affecting staff and residents.
Failed to maintain exit discharge with guardrail on exterior stair landing and had obstruction on exit discharge path.
Failed to ensure corridor doors positively latched and resisted passage of smoke as required by code.
Report Facts
Survey Census: 135
Total Capacity: 201
Sample Size: 31
Medication Error Rate: 12
Number of Deficient CNA Staffing Days: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 6 | Certified Nursing Assistant | Named in infection prevention and control deficiency related to improper PPE use and hand hygiene. |
| Charge Nurse 4 | Charge Nurse | Named in infection prevention and control deficiency related to improper PPE use and hand hygiene. |
| Charge Nurse 3 | Charge Nurse | Named in pharmacy services deficiency related to medication administration and documentation. |
| Regional Nurse | Educated staff on abuse investigation procedures. | |
| Director of Nursing | Director of Nursing | Responsible for oversight of multiple corrective actions including staffing, infection control, and medication administration. |
| Administrator | Administrator | Responsible for oversight of staffing and life safety corrective actions. |
| Maintenance Director | Maintenance Director | Responsible for oversight of life safety corrective actions including door and exit maintenance. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 28, 2024
Visit Reason
The inspection was conducted in response to complaint NJ00173949 to investigate compliance with staffing ratios and other regulatory requirements.
Complaint Details
Complaint #: NJ00173949. The facility was found to be in substantial compliance based on this complaint visit.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards due to failure to meet required minimum staff-to-resident ratios on 9 of 14 day shifts. The facility submitted a plan of correction addressing staffing vacancies, recruitment efforts, and quality assurance measures.
Deficiencies (1)
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 9 of 14 day shifts.
Report Facts
Census: 157
Deficient day shifts: 9
Sample Size: 3
CNA staffing counts: 16
CNA staffing counts: 19
CNA staffing counts: 17
CNA staffing counts: 18
CNA staffing counts: 18
CNA staffing counts: 17
CNA staffing counts: 20
CNA staffing counts: 20
CNA staffing counts: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Met with Director of Nursing and Staffing Coordinator to address staffing vacancies and recruitment | |
| Director of Nursing | Met with Administrator and Staffing Coordinator to address staffing vacancies and recruitment; involved in quality assurance and staffing ratio reviews | |
| Staffing Coordinator | Responsible for notifying Director of Nursing and Administrator when staffing ratios are not met | |
| Human Resource Director | Conducts exit interviews for nursing employees and participates in recruitment and quality assurance |
Inspection Report
Census: 27
Deficiencies: 1
Date: Aug 4, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, and homelike environment for residents.
Findings
The facility failed to maintain a safe, clean, and homelike environment in three resident rooms affecting four of 27 sampled residents. Observations included dirt buildup, exposed fan blades, soiled walls and floors, a broken headboard, and holes in walls, all verified by the Administrator.
Deficiencies (1)
Failure to maintain a safe, clean, and homelike environment including dirt buildup, exposed fan blades, soiled walls and floors, broken headboard, and holes in walls in resident rooms.
Report Facts
Residents sampled: 27
Residents affected: 4
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 2
Date: Aug 4, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers from 08/01/23 through 08/04/23.
Complaint Details
The complaint survey was based on multiple complaint numbers: NJ00160452, NJ00160767, NJ00160860, NJ00161873, NJ00162591, NJ00163313, NJ00163386, NJ00163835, and NJ00164143. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Findings
The facility was found not in substantial compliance with requirements for long term care facilities due to failure to maintain a safe, clean, and homelike environment in resident rooms and failure to meet required minimum staff-to-resident ratios on multiple day shifts.
Deficiencies (2)
Failure to maintain a safe, clean, comfortable, and homelike environment affecting four residents in three rooms, including soiled floors, walls, privacy curtains, exposed fan blades, and holes in walls.
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on 8 of 36 day shifts.
Report Facts
Survey Census: 139
Sample Size: 27
Deficient CNA staffing day shifts: 8
CNA staffing deficits: 6
CNA staffing deficits: 2
Residents on day shifts: 126
Residents on day shifts: 128
Residents on day shifts: 140
Residents on day shifts: 140
Residents on day shifts: 141
Residents on day shifts: 139
Residents on day shifts: 138
Inspection Report
Annual Inspection
Census: 126
Deficiencies: 11
Date: Nov 23, 2022
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. Deficiencies were cited for this survey.
Findings
The facility was found not in compliance with multiple regulatory requirements including safe environment, care plan implementation, medication administration, ADL care, infection prevention and control, staffing, and resident call system. Deficiencies included unclean environment, failure to apply ordered treatments, medication errors, inadequate ADL care, infection control breaches, insufficient staffing, and missing call bells.
Deficiencies (11)
Facility failed to provide a clean, comfortable homelike environment; heating/cooling units were dirty and in disrepair; rooms were soiled; temperatures were not maintained within range.
Failed to apply physician ordered interventions and administer medications with food as prescribed; improper disposal of medications observed.
Failed to provide appropriate ADL care for dependent residents; residents observed with soiled linens, unshaven facial hair, and inadequate repositioning.
Failed to ensure medications were administered per physician orders for multiple residents; failed to implement ordered interventions for pressure ulcer care.
Failed to ensure interventions to prevent falls were in place; incomplete post-fall assessments; failure to determine causal factors and implement interventions; missing call bells for residents.
Failed to post 24-hour nurse staffing information in a prominent and accessible location; staffing reports did not include actual hours worked by licensed and unlicensed staff.
Failed to document target behaviors for residents on behavior medications; failed to implement nonpharmacological interventions and develop care plans to manage behaviors.
Failed to maintain kitchen and pantry areas in a clean and sanitary manner; dish machine operated below required temperature; improper use of test strips; unlabeled and undated food items in refrigerators.
Failed to conduct and document a comprehensive facility-wide assessment including resources necessary to care for residents; failed to update assessment to include management of ongoing outbreak.
Failed to maintain an effective infection prevention and control program; staff failed to don required PPE and perform hand hygiene; housekeeping used ineffective cleaning products; poor communication with dialysis center regarding residents on transmission-based precautions; facility assessment lacked staff roles related to care of residents diagnosed with C. auris; infection preventionist lacked required training and certification.
Failed to ensure call bell system was in place for residents at bedside and in toilet/bathing facilities; missing call bells for residents #114 and #119.
Report Facts
Census: 126
Staffing deficiency days: 10
Residents: 125
Required CNAs: 16
Medication doses missed: 2
Weight loss: 11
Pressure ulcer size: 4.5
Pressure ulcer size: 3.5
Pressure ulcer size: 1.5
Pressure ulcer size: 1.5
Pressure ulcer size: 1.5
Pressure ulcer size: 1.5
Pressure ulcer size: 0.5
Pressure ulcer size: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication administration and treatment deficiencies |
| Unit Manager | Named in multiple findings including environment, ADL care, and infection control | |
| Certified Nursing Assistant (CNA) #1 | Named in behavior management deficiencies | |
| Certified Nursing Assistant (CNA) #2 | Named in call bell system deficiency | |
| Licensed Nursing Home Administrator (LNHA) | Named in QAPI and infection prevention deficiencies | |
| Assistant Director of Nursing (ADON) | Named in infection prevention and QAPI deficiencies | |
| Infection Preventionist (IP) | Named in infection prevention deficiencies | |
| Certified Dietary Manager (CDM) | Named in food safety deficiencies | |
| Licensed Practical Nurse Apprentice (LPNA) | Named in infection prevention deficiencies | |
| Licensed Practical Nurse (LPN) | Named in infection prevention and dialysis communication deficiencies | |
| Medical Director (MD) | Named in infection prevention and QAPI deficiencies | |
| Regional Licensed Nursing Home Administrator (RLNHA) | Named in infection prevention and QAPI deficiencies | |
| Regional Nurse (RN) | Named in infection prevention deficiencies | |
| Certified Nurse Aide (CNA) | Named in infection prevention deficiencies | |
| Licensed Practical Nurse (LPN) #3 | Named in infection prevention deficiencies | |
| Licensed Practical Nurse (LPN) #4 | Named in infection prevention deficiencies | |
| Licensed Practical Nurse (LPN) #2 | Named in infection prevention and medication administration deficiencies | |
| Certified Nurse Aide (CNA) #1 | Named in medication administration deficiencies | |
| Certified Nurse Aide (CNA) #2 | Named in medication administration deficiencies | |
| Certified Nurse Aide (CNA) #2 | Named in call bell system deficiency | |
| Certified Nurse Aide (CNA) #1 | Named in behavior management deficiencies | |
| Licensed Practical Nurse (LPN) #2 | Named in medication administration and treatment deficiencies | |
| Licensed Practical Nurse (LPN) #2 | Named in medication administration and treatment deficiencies | |
| Licensed Practical Nurse (LPN) #2 | Named in medication administration and treatment deficiencies | |
| Licensed Practical Nurse (LPN) #2 | Named in medication administration and treatment deficiencies | |
| Licensed Practical Nurse (LPN) #2 | Named in medication administration and treatment deficiencies | |
| Licensed Practical Nurse (LPN) #2 | Named in medication administration and treatment deficiencies | |
| Licensed Practical Nurse (LPN) #2 | Named in medication administration and treatment deficiencies | |
| Licensed Practical Nurse (LPN) #2 | Named in medication administration and treatment deficiencies |
Inspection Report
Life Safety
Deficiencies: 8
Date: Nov 16, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 11/16/2022 and 11/17/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for Alliance Care Rehabilitation and Nursing Center.
Findings
The facility was found noncompliant with multiple Life Safety Code requirements including vertical opening enclosures, fire alarm system installation, sprinkler system installation, portable fire extinguisher maintenance, smoke barrier door functionality, HVAC ventilation in resident bathrooms, elevator emergency communication, and emergency generator remote stop station.
Deficiencies (8)
Three of fourteen 1-1/2 hour fire rated stairwell doors failed to positive latch into their frame as required to maintain fire rated construction.
Facility failed to provide fire alarm notification by audible and visible signals for 1 enclosed outside patio area.
Facility failed to properly install sprinklers and provide proper fire sprinkler coverage in multiple areas, including missing escutcheon caps and missing sprinklers.
Facility failed to perform and document monthly visual examinations for 10 of 19 portable fire extinguishers and maintain one portable fire extinguisher in proper working condition.
Two of thirteen sets of corridor smoke barrier doors failed to maintain smoke barrier integrity due to improper closure and gaps.
Facility failed to ensure proper operation of 4 of 12 resident bathroom exhaust ventilation systems.
Facility failed to maintain elevator emergency communications for 2 of 2 elevators tested; emergency phones had busy signals.
Facility failed to ensure a remote manual stop station for 1 emergency generator was installed as required.
Report Facts
Fire rated stairwell doors tested: 14
Fire extinguishers inspected: 19
Resident bathrooms inspected: 12
Elevators tested: 2
Smoke barrier door sets tested: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Named in relation to multiple findings including stairwell door deficiencies, fire alarm and sprinkler system issues, fire extinguisher inspections, smoke barrier door maintenance, bathroom ventilation, elevator emergency communication, and emergency generator remote stop station | |
| Director of Nursing | Mentioned as present during survey and requested to provide facility layout | |
| Regional Administrator | Notified of deficiencies at Life Safety Code exit conference |
Inspection Report
Routine
Deficiencies: 9
Date: Nov 7, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including infection control, resident care, environment, and safety.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and safe environment, inadequate wound care and medication administration, insufficient assistance with activities of daily living, incomplete fall risk assessments and interventions, failure to properly manage residents with behavioral issues, inadequate infection control practices especially related to Candida Auris outbreak, insufficient staffing levels, and failure to post required staffing information.
Deficiencies (9)
Failure to maintain a clean, safe, and comfortable environment including dirty heating/cooling units, stained curtains, soiled floors, broken fixtures, and poor housekeeping.
Failure to apply physician ordered wound care interventions and offloading devices for Resident #105, resulting in potential worsening of wounds.
Failure to administer medications as ordered for multiple residents, including missed doses and improper disposal of medications.
Failure to provide adequate activities of daily living care including nail care, shaving, toileting, and call bell availability for multiple residents.
Failure to properly assess and intervene after resident falls, including incomplete fall risk assessments and lack of appropriate interventions.
Failure to post 24-hour nurse staffing information in a manner accessible to residents, families, and the public.
Failure to implement and maintain an effective infection prevention and control program, including improper PPE use, inadequate cleaning for Candida Auris, and poor communication with dialysis center regarding residents with C. Auris.
Failure to ensure the designated Infection Preventionist had required specialized training and certification, and failure to maintain adequate infection preventionist coverage.
Failure to ensure a working call bell system was available in residents' rooms and bathing areas for two residents.
Report Facts
Deficiencies cited: 9
Weight loss: 6
CNA staffing deficiency: 10
Resident #49 wound size: 37.75
Resident #49 wound size increase: 6.5
Resident #49 wound size increase: 5.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #2 | Acknowledged failure to apply heel boots and Ace wraps to Resident #105 and signing off treatments not applied | |
| Certified Nursing Assistant (CNA) #1 | Cared for Resident #105 and stated resident was alert and took care of most ADLs, but no responsibility for wound care | |
| Assistant Director of Nursing (ADON) #1 | Acting Infection Preventionist without specialized training | |
| Manager of Housekeeping | Acknowledged improper cleaning products used for Candida Auris and improper PPE donning/doffing by housekeeping staff | |
| Licensed Practical Nurse Apprentice (LPNA) | Failed to don proper PPE and perform hand hygiene when delivering meal tray to Resident #92 | |
| Licensed Nursing Home Administrator (LNHA) | Provided information on Infection Preventionist role and staffing deficiencies | |
| Assistant Director of Nursing Uncertified Appointed Infection Preventionist (ADONUAIP) | Filled in for IP on leave, lacked specialized training, and failed to ensure communication with dialysis center | |
| Director of Nursing (DON) | Newly hired, unaware of some infection control issues and failed to provide requested IP documentation | |
| Regional Licensed Nursing Home Administrator (RLNHA) | Provided information on facility assessment and infection control oversight | |
| Medical Director (MD) | Unaware of Candida Auris outbreak and infection preventionist identity | |
| Dialysis Nurse Manager (NM) | Unaware of some residents' C. Auris status and lack of communication from facility |
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 1
Date: Jun 9, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaints (NJ 146320, NJ 149775, NJ 153225, NJ 153470, NJ 154402) regarding the facility's compliance with professional standards and physician's orders.
Complaint Details
The complaint investigation involved multiple complaint numbers and focused on the facility's failure to follow physician's orders for Resident #1, which was substantiated by interviews, record reviews, and facility documents. The resident was not transferred timely to acute care despite physician orders, leading to the resident's death.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to follow physician's orders for one resident, which contributed to the resident's transfer delay to acute care and subsequent death. The investigation revealed lapses in communication and adherence to physician orders by nursing staff.
Deficiencies (1)
Failure to follow physician's order for Resident #1, including canceling 911 without notifying the primary physician, resulting in delayed transfer to acute care and resident's death.
Report Facts
Census: 125
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in the finding for failing to follow physician's order and canceling 911 without notifying the primary physician |
| RN #3 | Unit Manager | Assessed Resident #1 and was made aware of condition and physician orders |
| LPN #1 | Licensed Practical Nurse | Documented Resident #1's condition and notified Unit Manager |
| RN #2 | Registered Nurse | Received report from RN #1 about canceled 911 and administered medication |
| RN #4 | Nursing Supervisor | Unable to assess Resident #1 due to performing admissions; involved in communication |
| Primary Physician | Medical Director | Ordered transfer of Resident #1 to acute care hospital and provided physician orders |
| Director of Nursing | Director of Nursing (DON) | Responsible for QA monitoring and systemic changes |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 23, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to respiratory care, medication storage, infection prevention and control, and overall resident care at Alliance Care Rehabilitation and Nursing Center.
Findings
The facility was found deficient in providing appropriate respiratory care for a resident on oxygen therapy, proper labeling and storage of medications, and infection prevention practices including PPE use, hand hygiene, and disposal of tracheostomy care equipment. Deficiencies were noted in care planning, equipment maintenance, and staff adherence to protocols.
Deficiencies (3)
Failure to maintain necessary respiratory care and services for a resident receiving continuous oxygen treatment, including lack of a respiratory care plan and malfunctioning oxygen concentrator.
Failure to properly label, store, and dispose of medications in one of six medication carts inspected.
Failure to use appropriate personal protective equipment (PPE), disinfect equipment surfaces prior to tracheostomy care, properly dispose of tracheostomy inner cannula, and perform appropriate hand hygiene during medication pass.
Report Facts
Residents affected: 1
Residents affected: 1
Medication carts inspected: 6
Oxygen order liter flow: 2
Oxygen liter flow observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide (CNA) | Fed Resident #45 and stated nurse responsible for oxygen care | |
| Registered Nurse/Unit Manager (RN/UM) | Acknowledged responsibility for care plan initiation and oxygen order adherence | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Replaced broken oxygen concentrator and assessed Resident #45 | |
| Director of Nursing (DON) | Acknowledged care plan oversight and educated RN on oxygen order and equipment | |
| Licensed Nursing Home Administrator (LNHA) | Participated in meetings regarding deficiencies | |
| Regional Respiratory Therapist (RT) | Performed tracheostomy care and explained PPE use and disposal practices | |
| Infection Control Preventionist | Stated N95 mask use required for tracheostomy care and proper disposal protocols | |
| Licensed Practical Nurse (LPN) | Observed with medication cart during insulin vial labeling deficiency | |
| Registered Nurse (RN) | Observed washing hands improperly during medication pass |
Inspection Report
Routine
Census: 103
Deficiencies: 4
Date: Sep 23, 2021
Visit Reason
The inspection was a routine standard survey to assess compliance with state and federal regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including staffing ratios, respiratory care, medication labeling and storage, infection prevention and control, and hand hygiene practices. Deficiencies were identified related to inadequate staffing, failure to maintain care plans, improper medication storage and labeling, and lapses in infection control practices including PPE use and hand hygiene.
Deficiencies (4)
Failed to maintain required minimum direct care staff to resident ratios for the day shift as mandated by the state of New Jersey.
Failed to maintain necessary respiratory care and services for a resident receiving tracheostomy care according to standards of practice.
Failed to properly label, store, and dispose of medications in medication carts.
Failed to establish and maintain an infection prevention and control program including proper PPE use, disinfection of equipment, disposal of contaminated materials, and hand hygiene.
Report Facts
Census: 103
Sample Size: 24
Staffing ratios: 1
Staffing ratios: 12
Staffing ratios: 11
Staffing ratios: 10
Staffing ratios: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vice President of Operations | Stated efforts to comply with minimum staffing requirements. | |
| Director of Nursing | Reviewed staffing schedules and acknowledged lack of staffing policy. | |
| Staffing Coordinator | Prepared nursing schedules and acknowledged staffing shortages due to vacations and union contract limitations. | |
| Registered Nurse/Unit Manager | Acknowledged oversight in care plan initiation and updating. | |
| Licensed Practical Nurse/Unit Manager | Replaced broken respiratory equipment and assessed resident stability. | |
| Respiratory Therapist | Observed lapses in infection control including improper PPE use and disinfection. | |
| Infection Control Preventionist | Confirmed facility protocols and PPE requirements. |
Inspection Report
Life Safety
Census: 108
Capacity: 212
Deficiencies: 6
Date: Sep 23, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 09/22/21 and 09/23/21 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including delayed-egress locking arrangements, stairway markings, emergency lighting, sprinkler system maintenance, HVAC ventilation, and gas equipment storage. Multiple deficiencies were observed and verified by facility staff during the survey.
Deficiencies (6)
Failed to ensure 15-second delayed egress feature on 3 of 14 exit discharge doors would activate when tested.
Failed to provide stair thread marking stripes on each step, floor landings, and handrails in 4 stairwells.
Failed to provide battery backup emergency lighting independent of building electrical system above emergency generator transfer switch.
Failed to maintain sprinkler system ceiling smoke resistance and fire rating; missing ceiling tiles and escutcheon plates in multiple areas.
Failed to ensure resident bathroom ventilation systems were adequately maintained and functioning in multiple rooms.
Failed to store a cylinder of compressed oxygen gas in a safe manner to prevent tipping and rupture; unsecured and hissing oxygen tank observed.
Report Facts
Certified beds: 212
Census: 108
Exit discharge doors tested: 14
Delayed egress doors failed: 3
Stairwells observed: 4
Stairwells deficient: 4
Ceiling tile deficiencies: 15
Oxygen tanks in storage closet: 11
Full oxygen tanks: 4
Empty oxygen tanks: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to findings and observations of delayed egress doors, sprinkler system, emergency lighting, ventilation, and oxygen tank storage. | |
| Regional Plant Operations Director | Named in relation to findings and observations of delayed egress doors, sprinkler system, emergency lighting, ventilation, and oxygen tank storage. | |
| Administrator | Informed of all findings during Life Safety Code exit conference. |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Date: Jul 14, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ143006, NJ146177, NJ146102, and NJ145049.
Complaint Details
Complaint numbers NJ143006, NJ146177, NJ146102, and NJ145049 were investigated. The facility was found to be in compliance based on this complaint survey.
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.
Report Facts
Sample size: 11
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 0
Date: Feb 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on complaints #141225, 141811, and 142614.
Complaint Details
Complaint numbers NJ: 141225, 141811, 142614 were investigated and the facility was found to be in substantial compliance.
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.
Report Facts
Sample size: 4
Inspection Report
Complaint Investigation
Census: 129
Deficiencies: 0
Date: Dec 17, 2020
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00140400, NJ00140511, NJ00139733, NJ00140358, and NJ00138081.
Complaint Details
The survey was triggered by multiple complaints as listed, and the facility was found compliant with no deficiencies cited.
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.
Report Facts
Sample Size: 5
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