Inspection Reports for Atlas Healthcare At Daughters Of Miriam
155 Hazel Street, NJ, 07011
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
192 residents
Based on a October 2023 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 the notice |
Inspection Report
Complaint Investigation
Census: 192
Deficiencies: 3
Oct 20, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to multiple complaint numbers related to alleged violations at the facility.
Findings
The facility was found not in substantial compliance with federal requirements related to abuse reporting and quality of care. Specifically, the facility failed to timely report an injury of unknown origin for one resident and failed to administer physician-ordered medications as scheduled for another resident. Additionally, the facility did not meet required minimum staffing ratios as mandated by the state.
Complaint Details
The complaint investigation involved multiple complaint numbers and found the facility failed to report an injury of unknown origin for Resident 9 and failed to administer medications on time for Resident 6. The facility was not in substantial compliance with 42 CFR Part 483, Subpart B, based on this complaint visit.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report an injury of unknown origin to the state survey agency for one resident. | SS=D |
| Failure to administer physician ordered medications as scheduled for one resident. | SS=D |
| Failure to maintain required minimum staff-to-resident ratios as mandated by the state of New Jersey. | — |
Report Facts
Survey Census: 192
Sample Size: 12
Deficient CNA staffing shifts: 34
Deficient CNA staffing shifts: 1
Required CNA staffing: 23
Actual CNA staffing: 13
Medication administration times: 2
Inspection Report
Routine
Census: 192
Deficiencies: 0
Aug 12, 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 and preparedness for 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 to prepare for COVID-19.
Report Facts
Sample Size: 7
Inspection Report
Abbreviated Survey
Census: 186
Deficiencies: 0
Jul 6, 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: 5
Inspection Report
Annual Inspection
Census: 179
Capacity: 209
Deficiencies: 15
May 5, 2023
Visit Reason
A Recertification and Complaint Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health from 05/01/23 through 05/05/23 to assess compliance with federal and state regulations.
Findings
The facility was found not to be in substantial compliance with several regulatory requirements including infection control, resident assessments, assistance with activities of daily living, medication regimen review, psychotropic drug use, emergency preparedness, and life safety code requirements. Immediate Jeopardy was identified related to infection control practices with glucometer sanitization but was removed after corrective actions. Multiple deficiencies were cited related to resident care, documentation, and facility safety.
Complaint Details
The survey included a complaint investigation component triggered by allegations related to infection control and resident care deficiencies.
Severity Breakdown
SS=J: 1
SS=F: 4
SS=E: 3
SS=D: 6
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to sanitize glucometers between residents per manufacturer's instructions, resulting in Immediate Jeopardy for infection control. | SS=J |
| Failure to provide timely Minimum Data Set (MDS) resident assessments and transmit data as required. | SS=D |
| Failure to provide assistance with grooming and personal hygiene to dependent residents. | SS=E |
| Failure to ensure proper treatment and care planning for residents with hearing and vision impairments. | SS=D |
| Failure to consistently provide daily range of motion (ROM) services for residents with limited mobility. | SS=D |
| Failure to obtain physician orders and develop care plans for respiratory care including tracheostomy and suctioning. | SS=D |
| Failure to ensure medication regimen review was completed monthly by a pharmacist for all residents. | SS=D |
| Failure to ensure psychotropic drug use was properly monitored, including PRN orders and behavioral monitoring. | SS=D |
| Failure to provide emergency lighting at the emergency generator transfer switch. | SS=F |
| Failure to maintain vertical openings with proper fire-rated doors and latches. | SS=F |
| Failure to locate a manual fire alarm box within 60 inches of the exterior exit doors from the auditorium. | SS=E |
| Failure to perform smoke detection sensitivity testing every alternate year as required. | SS=F |
| Failure to ensure Ground Fault Circuit Interruption (GFCI) protection for electrical outlets within six feet of sinks. | SS=E |
| Failure to inspect fire door assemblies annually and maintain inspection records. | SS=F |
| Failure to maintain required minimum direct care staff to resident ratios for Certified Nurse Aides (CNAs) on day shifts for 31 of 42 days reviewed. | — |
Report Facts
Survey Census: 179
Total Capacity: 209
Sample Size: 43
Deficient CNA staffing days: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in infection control deficiency related to glucometer sanitization |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including infection control, medication regimen review, and resident care |
| Administrator | Facility Administrator | Named in infection control and staffing deficiencies |
| MDS Coordinator (MDSC2) | MDS Coordinator | Named in deficiency related to resident assessment data submission |
| Maintenance Director | Maintenance Director | Named in deficiencies related to emergency lighting, fire doors, fire alarm system, and electrical safety |
Inspection Report
Complaint Investigation
Census: 189
Deficiencies: 5
Jan 20, 2023
Visit Reason
Complaint survey triggered by complaint #NJ159325 and a COVID-19 Focused Infection Control Survey due to outbreak status and infection control concerns.
Findings
The facility was found non-compliant with infection control regulations including failure to ensure twice weekly staff COVID-19 testing, falsification of testing logs, failure to ensure proper N95 mask fit testing and use, improper PPE use, and inadequate infection prevention and control program implementation. The facility also failed to maintain an effective compliance and ethics program.
Complaint Details
Complaint #NJ159325 involved allegations of failure to comply with infection control regulations, falsification of staff COVID-19 testing logs, improper PPE use, and failure to maintain an effective compliance and ethics program. The complaint was substantiated based on observations, interviews, and document reviews.
Severity Breakdown
SS=F: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure staff COVID-19 testing was completed twice weekly as required and falsification of testing logs. | SS=F |
| Failure to ensure proper fit testing and use of N95 masks by staff, including agency staff, and failure to ensure proper PPE use. | SS=F |
| Failure to maintain an effective infection prevention and control program including cleaning of equipment between resident use. | SS=F |
| Failure to ensure COVID-19 testing of residents and staff was conducted according to community transmission levels and regulatory requirements. | SS=F |
| Failure to implement and enforce an effective compliance and ethics program, including failure to ensure integrity of reported testing data and falsification of respirator fit testing documentation. | SS=F |
Report Facts
Census: 189
Sample Size: 5
Employees fit tested: 144
Employees overdue for fit testing: 80
Agency staff without fit test: 47
Employees employed: 197
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #10 | Certified Nursing Assistant | Signed a fit test form without being fit tested for the required N95 mask. |
| UC #12 | Unit Clerk | Instructed by NHA to falsify staff COVID-19 testing logs and have employees sign them. |
| LPN #3 | Licensed Practical Nurse | Forgot to test for COVID-19 on a scheduled shift. |
| DON | Director of Nursing | Instructed staff to have CNA #10 sign fit test form; acknowledged lack of training for fit testing. |
| RDO | Regional Director of Operations | Expressed disbelief at falsification of documents and failure to comply with testing requirements. |
| IP Nurse | Infection Preventionist Nurse | Responsible for fit testing and infection control training; admitted incomplete agency staff fit testing records. |
| SC #11 | Staffing Coordinator | Asked CNA #10 to sign a blank fit testing form. |
Inspection Report
Complaint Investigation
Census: 175
Deficiencies: 0
Sep 7, 2022
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00156684.
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 number NJ00156684 was investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample size: 15
Inspection Report
Annual Inspection
Census: 144
Deficiencies: 0
May 5, 2021
Visit Reason
The inspection was conducted as a standard annual survey 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 for long term care facilities.
Report Facts
Sample records reviewed: 45
Inspection Report
Life Safety
Deficiencies: 0
May 4, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations 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 Daughters of Miriam Center was found to be in compliance with the Life Safety Code requirements, including emergency preparedness and fire safety standards. The facility is a multi-phase, multi-story structure divided into 19 smoke zones.
Report Facts
Smoke zones: 19
Stories: 5
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 1
Jan 20, 2021
Visit Reason
The inspection was conducted in response to complaints NJ: 141897 and 142675 regarding alleged staff to resident abuse involving Resident #1.
Findings
The facility failed to immediately report an allegation of staff to resident verbal abuse involving CNA #1 and Resident #1 to the New Jersey Department of Health as required by policy and regulation. The CNA was suspended and terminated, and staff were re-educated on abuse reporting and investigation procedures.
Complaint Details
The complaint involved verbal abuse by CNA #1 towards Resident #1, including demeaning language and failure to follow resident's care preferences. The incident was witnessed by CNA #2. The facility did not report the incident to NJDOH within the required 2-hour timeframe, reporting it instead 8 days later. The CNA was suspended and terminated, and staff were re-educated on abuse reporting policies.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to immediately report an allegation of staff to resident abuse involving Resident #1 as required by facility policy and state regulations. | SS=D |
Report Facts
Complaint numbers: 2
Resident census: 145
Sample size: 4
Days late reporting: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Aide | Named in verbal abuse incident and subsequent termination |
| CNA #2 | Certified Nursing Aide | Witness to abuse incident and re-educated on reporting |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding incident and facility reporting procedures |
| Unit Manager #1 | Unit Manager | Interviewed regarding incident and staff monitoring |
Inspection Report
Abbreviated Survey
Census: 145
Deficiencies: 1
Dec 14, 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 related to COVID-19.
Findings
The facility was found not in compliance with 42 CFR §483.80 infection control regulations due to failure to utilize appropriate personal protective equipment (PPE) by staff, specifically a Certified Nursing Assistant who did not wear a gown while in the COVID-19 positive unit. The facility lacked a policy specifying PPE requirements inside the unit.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to utilize appropriate personal protective equipment (PPE) to prevent the potential spread of infection, specifically a CNA not wearing a gown in the COVID-19 positive unit. | SS=D |
Report Facts
Sample size: 7
Deficiency completion date: Dec 30, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated CNAs were instructed to wear gowns inside the unit and acknowledged lack of a specific PPE policy |
| Registered Nurse Unit Manager | RN/UM | Provided information about PPE requirements outside the COVID-19 positive unit |
| Infection Control Nurse | Infection Control Nurse | Retrained CNA on proper PPE use and conducted staff training on PPE usage |
| Certified Nursing Assistant | CNA | Observed not wearing gown while in COVID-19 positive unit, admitted to improper PPE use |
Inspection Report
Routine
Census: 147
Deficiencies: 0
Nov 18, 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 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.
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