Inspection Reports for AristaCare at Norwood Terrace
40 Norwood Ave., Plainfield, NJ 07060, NJ, 07060
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
99 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, 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 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 questions about the notice |
Inspection Report
Annual Inspection
Deficiencies: 4
Apr 3, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements and evaluate the quality of care provided to residents at Aristacare at Norwood Terrace.
Findings
The facility was found deficient in multiple areas including failure to develop and implement complete care plans addressing residents' medical needs, failure to provide timely incontinence care, improper catheter care with drainage bags contacting the floor, and inadequate infection control measures related to respiratory equipment handling and storage.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to develop and implement a care plan that meets the medical needs identified on the comprehensive assessment for Resident #94, specifically lacking oxygen use interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure timely incontinence care for Resident #73, with observations of strong odors and stained briefs and bed pads, and lack of documentation of refusal of care. | Level of Harm - Minimal harm or potential for actual harm |
| Allowed catheter drainage bag and tubing to be in contact with the floor for Resident #7, increasing risk of infection. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement infection control measures for respiratory equipment by leaving Resident #94's nasal cannula exposed and not stored in a plastic bag when not in use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for comprehensive care plans: 20
Residents reviewed for incontinence care: 20
Residents reviewed for urinary catheter or UTI: 1
Residents reviewed for respiratory care: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager Licensed Practical Nurse (UMLPN) | Interviewed regarding care planning and respiratory equipment storage for Resident #94 | |
| Director of Nursing (DON) | Interviewed regarding care planning, catheter care, and respiratory equipment infection control | |
| Registered Nurse/Unit Manager (RN/UM) | Interviewed regarding incontinence care for Resident #73 |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 5
Apr 3, 2025
Visit Reason
The inspection was conducted based on multiple complaints alleging deficiencies at the facility, including failure to maintain adequate staffing and failure to meet care plan and infection control requirements.
Findings
The facility was found not in substantial compliance with federal and state regulations, with deficiencies in comprehensive care planning, timely provision of ADL care, catheter care, infection prevention and control, and mandatory staffing ratios. Specific issues included failure to develop adequate care plans for residents, inadequate incontinent care, improper catheter bag placement, improper storage of respiratory equipment, and failure to maintain required CNA staffing ratios.
Complaint Details
The visit was complaint-driven based on multiple complaint numbers NJ178791, NJ177285, NJ177295, NJ175438, NJ173153, and NJ184711. The complaints included allegations of inadequate care planning, insufficient ADL care, improper catheter care, infection control lapses, and staffing shortages.
Severity Breakdown
SS=D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive care plan that meets the medical needs identified on the comprehensive assessment for Resident #94. | SS=D |
| Failure to ensure timely provision of ADL care for a dependent resident (Resident #73). | SS=D |
| Failure to provide appropriate catheter care, allowing catheter drainage bag and outer covering to contact the floor for Resident #7. | SS=D |
| Failure to implement infection control measures for handling and storage of oxygen equipment for Resident #94. | SS=D |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law. | — |
Report Facts
Census: 99
Staffing deficiency counts: 19
Required CNA staffing: 12
Actual CNA staffing: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to re-education of nurses and auditing care plans and catheter care | |
| Unit Manager Licensed Practical Nurse (UMLPN) #1 | Interviewed regarding care planning for Resident #94 | |
| Staffing Coordinator | Interviewed regarding staffing challenges and efforts to recruit staff | |
| Infection Preventionist | Responsible for re-education and auditing infection control practices |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Mar 7, 2024
Visit Reason
A Recertification and Complaint Survey was conducted on behalf of the New Jersey Department of Health due to multiple complaints identified by complaint numbers NJ 156145, NJ 158153, NJ 161805, NJ 161926, NJ 166893, NJ 162994, NJ 164343, and NJ 167727.
Findings
The facility was found to be not in compliance with New Jersey Administrative Code standards, specifically failing to meet mandatory minimum staffing ratios for CNAs and total staff on multiple day and overnight shifts across several weeks in 2023 and early 2024.
Complaint Details
The survey was complaint-driven with multiple complaint numbers listed. The facility was found deficient in staffing ratios based on review of facility documentation and state staffing requirements. The facility must submit a plan of correction to address these deficiencies.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-ratios as mandated by the state of New Jersey, including CNA staffing deficiencies on multiple day shifts and total staff deficiencies on overnight shifts. |
Report Facts
Survey Census: 97
Sample Size: 19
Staffing Deficiencies: 5
Staffing Deficiencies: 1
Staffing Deficiencies: 4
Staffing Deficiencies: 5
Staffing Deficiencies: 11
Staffing Deficiencies: 8
Staffing Deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named as part of the team meeting weekly to discuss recruitment efforts | |
| Director of Nursing | Named as part of the team meeting weekly to discuss recruitment efforts and reporting findings during Quality Assurance meetings | |
| Human Resources | Named as part of the team meeting weekly to discuss recruitment efforts | |
| Staffing Coordinator | Named as part of the team meeting weekly to discuss recruitment efforts |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 26, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Aristacare at Norwood Terrace.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 96
Deficiencies: 0
Sep 26, 2023
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.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 6
Inspection Report
Annual Inspection
Deficiencies: 5
Feb 2, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medication administration, catheter care, respiratory care, and food safety at Aristacare at Norwood Terrace nursing home.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments in the Minimum Data Set (MDS), failure to maintain professional standards in medication and treatment administration, lack of physician orders for catheter and oxygen care, and improper food handling and kitchen sanitation practices. Deficiencies were generally of minimal harm or potential for actual harm affecting a few or some residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to accurately assess residents' status in the Minimum Data Set (MDS), including incorrect coding of indwelling catheter use and tobacco use for residents #31 and #21. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain professional standards of clinical practice for residents #8 and #66, including incorrect documentation of heel boots application and failure to transcribe medication patch removal orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain physician orders for urinary catheter care for Resident #31, including catheter bag changes and catheter size/frequency. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain a physician order for oxygen use for Resident #19 despite continuous oxygen administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly handle and store potentially hazardous foods and maintain kitchen equipment to prevent microbial growth and cross contamination, including unlabeled and unrefrigerated food items, dented cans, wet pans, and dish machine not reaching required rinse temperature. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 22
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Order date: 2012
Order date: 2017
Order date: 2016
Inspection date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding MDS accuracy and acknowledged lack of physician order for oxygen | |
| Minimum Data Set Coordinator | MDSC | Interviewed regarding inaccurate MDS assessments for residents #21 and #31 |
| Licensed Practical Nurse | LPN | Interviewed regarding heel boots use for Resident #8 and oxygen use for Resident #19 |
| Unit Manager/Licensed Practical Nurse | UM/LPN | Interviewed regarding catheter care and heel boots documentation |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding heel boots orders and documentation |
| Licensed Practical Nurse Nurse Manager | LPN/NM | Interviewed regarding oxygen use and physician orders for Resident #19 |
| Director of Dietary | DOD | Present during kitchen inspection and confirmed food safety and sanitation deficiencies |
| Dietary Aide | DA | Observed operating dish machine during kitchen inspection |
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 17
Feb 2, 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 accuracy of assessments, professional standards of care, medication administration, infection control, food safety, emergency preparedness, life safety code violations, and staffing ratios.
Severity Breakdown
SS=D: 9
SS=E: 6
SS=F: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to accurately assess two residents' status in the Minimum Data Set (MDS). | SS=D |
| Failed to maintain professional standards of care in comprehensive care plans for residents. | SS=D |
| Failed to maintain proper documentation and physician orders for treatment administration and catheter care. | SS=D |
| Failed to provide respiratory care consistent with professional standards. | SS=D |
| Failed to maintain food safety including proper labeling, storage, and dishwasher temperature compliance. | SS=E |
| Failed to maintain required minimum direct care staff-to-resident ratios for day, evening, and overnight shifts. | — |
| Failed to maintain exit access free from obstructions. | SS=D |
| Failed to provide exit discharge doors readily accessible and free of obstructions or impediments. | SS=E |
| Failed to provide battery backup emergency light above emergency generator transfer switch. | SS=E |
| Failed to provide illuminated exit signs to clearly identify exit access path. | SS=D |
| Failed to ensure exit access stairwell doors positively latch to maintain fire rated construction. | SS=F |
| Failed to ensure fire-rated doors to hazardous areas were self-closing and separated by smoke resisting partitions. | SS=E |
| Failed to inspect range-hood fire suppression system semi-annually in accordance with NFPA 96. | SS=E |
| Failed to ensure corridor doors resist passage of smoke and have positive latching hardware. | SS=D |
| Failed to maintain smoke barrier doors to resist transfer of smoke when completely closed. | SS=E |
| Failed to ensure electrical outlets near water sources were equipped with Ground-Fault Circuit Interrupter (GFCI) protection. | SS=D |
| Failed to ensure remote manual stop station for emergency generator was installed. | SS=E |
Report Facts
Census: 107
Staffing Deficiency Days: 12
Staffing Deficiency Days: 1
Staffing Deficiency Days: 1
Deficiency Counts: 34
Fire Rated Corridor Doors Failed: 4
Smoke Barrier Doors: 6
Smoke Barrier Doors Failed: 1
Electrical Outlets Tested: 10
Electrical Outlets Failed: 4
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 3
May 4, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health based on complaint #NJ00153883 regarding medication errors and infection control practices.
Findings
The facility was found not in compliance with infection control regulations related to COVID-19 and failed to ensure residents were free from significant medication errors. Deficiencies included medication administration errors for Residents #2 and #5, failure to implement investigation policies, and improper use of personal protective equipment (PPE) during a COVID-19 outbreak.
Complaint Details
Complaint #NJ00153883 involved medication errors for Residents #2 and #5 and infection control deficiencies. The complaint was substantiated with findings of medication errors and failure to follow infection control policies.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to administer medications according to physician's orders for Residents #2 and #5, resulting in significant medication errors. | SS=D |
| Failed to ensure governing body implemented policies and investigations related to medication errors for Residents #2 and #5. | SS=D |
| Failed to establish and maintain an infection prevention and control program, including improper use of PPE by staff during a COVID-19 outbreak. | SS=D |
Report Facts
Sample size: 8
Census: 97
Deficiency correction completion date: May 26, 2022
Deficiency correction completion date: Jun 3, 2022
Residents on 2nd floor COVID-19 positive: 10
Residents under observation for COVID-19: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding medication errors and infection control; stated medication errors were identified and nurses educated | |
| LPN #1 | Licensed Practical Nurse | Observed not using full PPE during COVID-19 outbreak; disciplined and reeducated |
| Unit Manager (UM #1) | Unit Manager | Interviewed regarding COVID-19 outbreak and resident observation |
| Infection Control Preventionist (ICP) | Infection Control Preventionist | Interviewed regarding infection control practices and resident monitoring |
| Administrator | Facility Administrator | Interviewed regarding medication errors and facility policies |
Inspection Report
Plan of Correction
Census: 90
Deficiencies: 1
Jan 21, 2022
Visit Reason
The inspection was conducted as a Federal Infection Control Survey to assess compliance with New Jersey staffing requirements for nursing homes.
Findings
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey, with deficiencies in CNA staffing for 6 of 14 day shifts and total staff for residents on 1 of 14 overnight shifts.
Deficiencies (1)
| Description |
|---|
| Facility failed to maintain required minimum direct care staff-to-resident ratios, deficient in CNA staffing for 6 of 14 day shifts and total staff for residents on 1 of 14 overnight shifts. |
Report Facts
CNA staffing deficiency days: 6
Overnight staffing deficiency days: 1
Residents present: 90
Required CNAs: 11
Required CNAs: 12
Required total staff overnight: 6
Inspection Report
Routine
Deficiencies: 3
Apr 6, 2021
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical services, medication administration, and medication error rates, including review of controlled substances management and antipsychotic medication administration.
Findings
The facility failed to timely remove discontinued and expired controlled drugs from inventory, maintain accurate accountability and reconciliation of controlled drugs, and ensure medication administration error rates were below 5%. Additionally, the facility failed to ensure a resident received a scheduled long-acting antipsychotic medication dose and lacked a comprehensive care plan for that medication.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to remove discontinued and expired controlled drugs (Valium and Ativan) from active inventory and maintain accountability and reconciliation. | Level of Harm - Minimal harm or potential for actual harm |
| Medication administration error rate of 5.8% observed during medication pass, exceeding the 5% threshold. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a long-acting antipsychotic medication (Haldol) was administered every 28 days as per psychiatric plan and lack of a comprehensive care plan addressing this medication. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration opportunities: 34
Medication administration errors: 2
Medication administration error rate: 5.8
Controlled drug counts: 15
Controlled drug volume: 30
Controlled drug volume remaining: 13
Haldol dose: 50
Haldol dose delay: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Named in findings related to controlled drug accountability and medication administration errors | |
| Unit Manager/LPN (UM/LPN) | Named in findings related to controlled drug accountability and medication administration errors | |
| Director of Nursing (DON) | Named in findings related to controlled drug policies and medication administration oversight | |
| Consultant Pharmacist (CP) | Named in findings related to medication pass observations and unit inspections | |
| Certified Nursing Aide (CNA) | Interviewed regarding Resident #227's behaviors and care | |
| LPN/Unit Manager (LPN/UM) | Interviewed regarding Resident #227's medication regimen and care plan | |
| Case Manager | Interviewed regarding Resident #227's Haldol administration in the community behavioral health clinic | |
| Psychiatrist | Consulted regarding Resident #227's antipsychotic medication regimen and monitoring |
Inspection Report
Life Safety
Deficiencies: 0
Apr 6, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with emergency preparedness requirements and in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 3
Apr 6, 2021
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 pharmacy services including failure to timely remove discontinued controlled drugs, medication administration errors exceeding 5%, and failure to ensure residents were free of significant medication errors including missed long-acting medication doses.
Complaint Details
Complaint #: NJ000142181
Severity Breakdown
SS=E: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to timely remove discontinued and expired controlled drugs from active inventory and perform accountability and reconciliation. | SS=E |
| Medication administration error rate of 5.8% observed during medication pass, exceeding the 5% threshold. | SS=D |
| Failure to ensure residents were free of significant medication errors, including missed long-acting medication dose for Resident #227. | SS=D |
Report Facts
Census: 76
Medication administration opportunities: 34
Medication administration errors: 2
Medication administration error rate: 5.8
Long-acting medication dose interval: 28
Missed dose interval: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Named in medication error findings and medication accountability issues | |
| Director of Nursing (DON) | Involved in findings related to medication errors, pharmacy services, and medication reconciliation | |
| Consultant Pharmacist (CP) | Interviewed regarding pharmacy services and medication pass observations | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding facility medication policies and findings | |
| Unit Manager/LPN (UM/LPN) | Interviewed regarding medication accountability and controlled drug administration records |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Jan 6, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ128250 and NJ125312.
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 #: NJ128250 and NJ125312; The facility was found in compliance based on this complaint survey.
Report Facts
Sample Size: 5
Inspection Report
Routine
Census: 83
Deficiencies: 0
Jan 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with Medicare regulations and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in substantial compliance with Medicare regulations at 42 CFR Part 483, Subpart B, and had implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 78
Deficiencies: 0
Dec 28, 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.
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: 5
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