Inspection Reports for AristaCare at Norwood Terrace
40 Norwood Ave., Plainfield, NJ 07060, NJ, 07060
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
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
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
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
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
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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