Inspection Reports for Aster Creek Nursing And Rehabilitation Center
524 Wardell Road, NJ, 07753
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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 explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and NJDHSS's legal duties 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
Routine
Census: 73
Capacity: 100
Deficiencies: 15
Oct 8, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe, clean, and homelike environment, inadequate comprehensive care plans, failure to ensure free of accident hazards, respiratory care issues, food safety violations, infection control deficiencies, and life safety code violations. Corrective actions and plans of correction were submitted and are in progress.
Complaint Details
Complaint # NJ171444 triggered the recertification survey.
Severity Breakdown
Level 3: 14
Immediate Jeopardy: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to maintain residents' living environment in a clean, comfortable, homelike manner, including issues with handrails, wallpaper, thresholds, and flooring. | Level 3 |
| Failure to revise an individual comprehensive care plan for a resident with a fall. | Level 3 |
| Failure to ensure a resident assessed for safety was provided adequate supervision and assistance devices to prevent accidents. | Level 3 |
| Failure to label, date, and properly store respiratory care equipment and oxygen tubing. | Level 3 |
| Failure to discard potentially hazardous food items and maintain food safety standards. | Level 3 |
| Failure to maintain proper hand hygiene and infection prevention practices among staff. | Level 3 |
| Failure to properly dispose of garbage and maintain outdoor trash areas. | Level 3 |
| Failure to maintain minimum staffing requirements for certified nurse aides. | Level 3 |
| Failure to ensure employees received required health examinations and tuberculosis testing. | Level 3 |
| Failure to maintain fire sprinkler system and fire alarm system in proper working order. | Immediate Jeopardy |
| Failure to maintain means of egress free of obstructions and ensure doors close and latch properly. | Level 3 |
| Failure to maintain hazardous areas separated by fire barriers and maintain fire doors. | Level 3 |
| Failure to maintain fire drills and fire doors in accordance with NFPA standards. | Level 3 |
| Failure to maintain safe storage and handling of oxygen and medical gases. | Level 3 |
| Failure to maintain smoking regulations and safe smoking areas. | Level 3 |
Report Facts
Census: 73
Total Capacity: 100
Deficiencies cited: 15
Staffing Deficiency: 7
Staffing Deficiency: 8
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 16
Sep 1, 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 emergency preparedness, resident rights, food safety, sanitation, garbage disposal, medical record documentation, staffing ratios, and life safety code compliance including fire safety, sprinkler system, exit signage, fire alarm system, and elevator safety.
Severity Breakdown
SS=F: 3
SS=E: 6
SS=D: 5
Deficiencies (16)
| Description | Severity |
|---|---|
| Facility failed to maintain a 3-day emergency food supply with unexpired items as required by emergency preparedness policies. | SS=F |
| Facility failed to treat a resident with respect and dignity, resulting in inappropriate staff-resident interaction. | SS=D |
| Facility failed to store, label, and date potentially hazardous foods properly, maintain kitchen equipment sanitation, and enforce hairnet use. | SS=E |
| Facility failed to maintain garbage area free of debris and furniture. | SS=D |
| Facility failed to maintain accurate and complete medical records for a resident with a change in condition, including timely documentation of assessments and vital signs. | SS=D |
| Facility failed to maintain required minimum direct care staff-to-shift ratios for 6 of 14 day shifts reviewed. | — |
| Facility building is a two-story unprotected ordinary-type construction not compliant with NFPA 101:2012 construction type requirements. | SS=E |
| Facility failed to provide a stable, suitable, and obstruction-free exit discharge path at one designated exit. | SS=D |
| Facility failed to provide two illuminated exit signs to clearly identify exit access paths. | SS=D |
| Facility failed to provide fire alarm notification by audible and visible signals for the outside second floor resident smoking patio area. | SS=E |
| Facility failed to provide fire sprinkler coverage to all areas, including elevator mechanical room. | SS=E |
| Facility failed to follow Plan of Correction for fire sprinkler system conversion and did not meet time limited waiver completion date. | SS=F |
| Facility failed to perform hydrostatic testing for 13 of 21 fire extinguishers as required. | SS=E |
| Facility failed to ensure corridor doors resist passage of smoke due to excessive gaps at top or bottom of doors. | SS=D |
| Facility failed to maintain elevator emergency communication phone in proper working condition. | SS=E |
| Facility failed to provide a working remote annunciator panel for emergency generator electrical system. | SS=E |
Report Facts
Deficiencies cited: 15
Resident census: 72
Staffing deficiency days: 6
Fire extinguisher hydrostatic testing overdue: 13
Resident rooms: 39
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Mar 22, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation to assess compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The facility was found to be in substantial compliance with the regulatory requirements based on this complaint visit.
Complaint Details
The facility was inspected following a complaint and was found to be in substantial compliance with no deficiencies cited.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Jul 19, 2021
Visit Reason
Complaint investigation related to safety concerns involving residents smoking in unauthorized areas and failure to update care plans and provide a safe environment.
Findings
The facility failed to provide a safe environment and adequately assess and monitor residents who violated smoking policies, resulting in multiple infractions and an Immediate Jeopardy situation. Care plans were not updated timely, staff were not adequately trained, and supervision was insufficient. The facility also failed to implement effective quality assurance measures to prevent recurrence.
Complaint Details
Complaint NJ146055 involved unsafe smoking practices by residents, failure to update care plans, and inadequate supervision leading to an Immediate Jeopardy situation.
Severity Breakdown
G: 1
K: 1
D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to update, revise, and implement care plan interventions for residents with multiple smoking infractions. | G |
| Failure to provide a safe environment and adequate supervision to prevent accidents and injuries related to smoking violations. | K |
| Failure to develop and implement appropriate quality assessment and assurance plans to correct identified deficiencies related to resident safety and smoking incidents. | D |
Report Facts
Census: 54
Sample Size: 4
Q15 minute checks: 15
Dates of incidents: 6
Dates of corrective action completion: Completion dates for plans of correction: 07/20/2021, 07/24/2021, 07/28/2021.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Educated residents about dangers of smoking with oxygen present; admitted awareness of incidents. |
| LPN #2 | Licensed Practical Nurse | Reported smoking incident and communicated with Nursing Supervisor. |
| DON | Director of Nursing | Informed of Immediate Jeopardy, responsible for audits and staff education. |
| LNHA | Licensed Nursing Home Administrator | Reported Immediate Jeopardy, involved in monitoring and corrective actions. |
| SW | Social Worker | Interviewed residents regarding smoking incidents and coordinated hospital placement. |
| AD | Activity Director | Managed smoking contracts and resident supplies. |
| CNA #1 | Certified Nursing Assistant | Monitored resident and reported smoking behaviors. |
| CNA #2 | Certified Nursing Assistant | Present during education of residents about smoking dangers. |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 3
Jun 14, 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 respiratory/tracheostomy care, failure to maintain required minimum direct care staff-to-resident ratios, and infection prevention and control practices including improper PPE use and hand hygiene.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to assess and obtain a physician's order for self-administration of oxygen, label, date, and initial oxygen tubing, update care plan for self-administration of oxygen, and ensure proper storage of oxygen equipment. | SS=D |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | SS=D |
| Failure to maintain proper infection control practices for donning appropriate PPE prior to entering isolation rooms and failure to maintain appropriate hand hygiene practices. | SS=D |
Report Facts
Census: 56
Sample Size: 22
Staff to Resident Ratio: 10.3
Staff to Resident Ratio: 10.7
Staff to Resident Ratio: 8
Resident Census: 31
Resident Census: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed and confirmed oxygen equipment issues and resident non-compliance with care |
| LPN #2 | Licensed Practical Nurse | Provided CNA assignment schedule and staffing information |
| Certified Nurses Aide (CNA) #1 | Certified Nurses Aide | Observed entering isolation room without proper PPE and delivering care |
| Certified Nurses Aide (CNA) #2 | Certified Nurses Aide | Observed entering isolation room without proper PPE and delivering care |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding oxygen self-administration, staffing, and infection control practices |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding staffing and infection control practices |
| Food Service Director | Food Service Director (FSD) | Interviewed and observed during kitchen hand hygiene and trash receptacle issues |
| Cook | Cook | Observed hand hygiene and improper trash receptacle handling |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
May 10, 2021
Visit Reason
This complaint investigation was conducted to determine compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on a complaint visit.
Findings
The facility was found not in substantial compliance due to failure to consistently implement the Resident's Care Plan for one of three residents reviewed, specifically related to monitoring and securing hand sanitizer to prevent resident access. The deficiency was supported by interviews, record reviews, and observations.
Complaint Details
The complaint investigation found the facility failed to ensure the Resident's Care Plan was consistently implemented for Resident #1, who had a history of consuming hand sanitizer. Staff failed to check the resident's room twice a shift to ensure no hand sanitizer was accessible, as required by the care plan. The resident was found with an empty bottle of hand sanitizer and was transferred for evaluation after a reportable event. Interviews with nursing staff and the Director of Nursing confirmed lack of awareness and documentation of required checks.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan consistent with resident rights, including measurable objectives and timeframes to meet resident's medical, nursing, mental and psychosocial needs. | SS=D |
Report Facts
Census: 52
Sample Size: 3
Deficiency Completion Date: Jun 1, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed on 5/10/21 and stated unawareness of the Resident's Focus Care Plan intervention until April 2021 |
| Nurse Supervisor | Nurse Supervisor | Interviewed on 5/10/21 and stated nurses were responsible for checking Resident #1's room and documenting it |
| Certified Nursing Assistant | Certified Nursing Assistant | Interviewed on 5/10/21 and stated unawareness of the requirement to check Resident #1's room twice a shift |
| Licensed Practical Nurse | Licensed Practical Nurse | Interviewed on 5/10/21 and stated unawareness of the requirement to check Resident #1's room twice a shift |
Inspection Report
Routine
Census: 43
Deficiencies: 0
Jan 29, 2021
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 related to COVID-19.
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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