Notice
Deficiencies: 0
Nov 19, 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 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 | Named as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 1
Feb 13, 2025
Visit Reason
The inspection was conducted in response to complaints NJ176893, NJ182412, and NJ182443 to investigate staffing ratio compliance at Avant Rehabilitation and Care Center.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39-5.1(a) regarding mandatory access to care due to failure to meet required staffing ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint numbers NJ176893, NJ182412, and NJ182443 were investigated. The facility was found deficient in CNA staffing for residents on all 14 day shifts reviewed from 01/26/2025 to 02/08/2025. The facility was in substantial compliance based on this complaint visit.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 14 of 14 day shifts reviewed, specifically CNA staffing shortages. |
Report Facts
Census: 132
Deficient CNA staffing days: 14
Required CNAs per day shift: 17
Actual CNAs on day shifts: 11
Sample size: 9
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 8
Mar 21, 2024
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 reasonable accommodations, professional standards of care, nutrition/hydration status, dialysis communication, RN staffing, infection prevention and control, and mandatory access to care staffing ratios.
Severity Breakdown
SS=D: 4
SS=E: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to maintain the call bell within reach of a resident. | SS=D |
| Failed to notify physician of resident's multiple medication refusals and maintain documentation. | SS=E |
| Failed to maintain and monitor functionality of a resident's medical device according to professional standards. | SS=E |
| Failed to ensure accuracy of re-admission nutrition assessment for a resident with significant weight loss. | SS=D |
| Failed to consistently complete dialysis communication form and maintain resident's communication record. | SS=E |
| Failed to ensure a Registered Nurse worked at least 8 consecutive hours a day, 7 days a week on multiple days. | SS=D |
| Failed to maintain infection control standards during wound care treatment, including hand hygiene and sanitizing surfaces. | SS=D |
| Failed to maintain required minimum direct care staff-to-resident ratios for certified nursing aides on multiple shifts. | — |
Report Facts
Census: 91
Deficient CNA staffing shifts: 26
Deficient CNA staffing overnight shifts: 1
RN staffing deficiency days: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager/Licensed Practical Nurse | UM/LPN | Acknowledged call bell and medication refusal documentation issues, dialysis communication record issues, and infection control deficiencies. |
| Director of Nursing | DON | Acknowledged multiple deficiencies including call bell placement, medication refusal notification, RN staffing, and infection control. |
| Licensed Nursing Home Administrator | LNHA | Participated in interviews and acknowledged staffing and documentation deficiencies. |
| Registered Dietitian | RD | Reviewed nutrition assessments and acknowledged inaccurate re-admission weight documentation. |
| Infection Preventionist | Provided education and competency validation on hand hygiene and wound care procedures. |
Inspection Report
Life Safety
Census: 89
Capacity: 149
Deficiencies: 0
Mar 20, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Survey were conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health on 03/20/2024.
Findings
The facility was found to be in compliance with 42 CFR 483.73 for Emergency Preparedness and with 42 CFR 483.90(a), Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19 Existing Health Care Occupancy.
Report Facts
Occupied beds: 89
Total licensed capacity: 149
Percentage of building covered by generator: 50
Inspection Report
Routine
Census: 86
Deficiencies: 0
Jun 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.
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
Complaint Investigation
Census: 103
Capacity: 149
Deficiencies: 25
Oct 12, 2022
Visit Reason
Complaint investigations were conducted based on multiple complaints regarding resident care, abuse allegations, infection control, and regulatory compliance.
Findings
The facility was found deficient in multiple areas including failure to prevent resident abuse, inadequate infection control practices during a COVID-19 outbreak, insufficient staffing levels, incomplete medical records, failure to complete required assessments, and failure to maintain a safe physical environment. Immediate Jeopardy situations were identified related to abuse, infection control, and staff vaccination compliance. Plans of correction were submitted and some deficiencies were corrected by the revisit dates.
Complaint Details
Complaints included allegations of resident abuse, neglect, infection control failures, inadequate staffing, and failure to provide necessary care and services. Multiple Immediate Jeopardy situations were identified related to abuse and infection control.
Severity Breakdown
Level L: 4
Level F: 9
Level E: 5
Level D: 5
Level C: 1
Deficiencies (25)
| Description | Severity |
|---|---|
| Failure to ensure vulnerable residents were free from abuse and protected from further abuse. | Level L |
| Failure to implement effective infection control program limiting spread of COVID-19. | Level L |
| Failure to maintain required minimum direct care staff to resident ratios. | Level D |
| Failure to complete comprehensive and quarterly Minimum Data Set assessments timely. | Level D |
| Failure to develop and implement comprehensive person-centered care plans. | Level E |
| Failure to provide necessary ADL care to dependent residents. | Level D |
| Failure to provide behavioral health services as ordered. | Level E |
| Failure to provide pharmaceutical services including removal of discontinued and expired medications. | Level E |
| Failure to store and label drugs and biologicals properly. | Level E |
| Failure to maintain sanitary food storage and preparation areas. | Level F |
| Failure to administer adequate nursing services to maintain resident well-being. | Level F |
| Failure to post complete and accurate nurse staffing information daily. | Level C |
| Failure to ensure nursing staff competencies and skills were maintained and documented. | Level F |
| Failure to maintain written transfer agreements with hospitals. | Level F |
| Failure to employ a qualified social worker with required experience. | Level F |
| Failure of QAPI committee to identify and correct quality deficiencies in a timely manner. | Level F |
| Failure to conduct timely COVID-19 testing and contact tracing during outbreak. | Level L |
| Failure to employ an infection preventionist with specialized training. | Level F |
| Failure to offer pneumococcal and influenza immunizations to residents. | Level D |
| Failure to ensure all staff were fully vaccinated for COVID-19 or properly exempted and tested. | Level L |
| Failure to maintain corridors with firmly secured handrails. | Level D |
| Failure to maintain elevator emergency communication systems. | Level E |
| Failure to provide remote manual stop station for emergency generator. | Level E |
| Failure to maintain fire rated construction on vertical openings and smoke barrier doors. | Level D |
| Failure to maintain portable fire extinguishers in proper condition and location. | Level D |
Report Facts
Resident census: 103
Total licensed capacity: 149
Deficient CNA staffing days: 12
Number of staff not up to date with COVID-19 vaccination: 32
Number of staff tested for COVID-19 during outbreak: 3
Number of shifts worked by unvaccinated LPN: 47
Number of fire extinguishers inspected: 16
Number of elevators: 3
Number of smoke barrier doors tested: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Worked 47 shifts during COVID outbreak without vaccination booster or fit testing |
| LPN #2 | Licensed Practical Nurse | Not fit tested for N95 mask, signed waiver declining booster |
| CNA #1 | Certified Nursing Assistant | Entered facility without completing COVID screening, wore surgical mask instead of N95 during outbreak |
| BA #1 | Behavioral Aide | Wore N95 mask improperly during COVID outbreak |
| Infection Preventionist | Infection Preventionist | Did not have CDC specialized training, responsible for COVID testing and contact tracing |
| Director of Nursing | Director of Nursing | Responsible for oversight of infection control and staff vaccination compliance |
| Administrator | Facility Administrator | Responsible for facility operations and compliance with regulations |
| Social Worker | Social Worker | Did not meet required experience, lacked training and guidance |
| Medical Director | Medical Director | Limited involvement in facility medical oversight and QAPI |
| Director of Human Resources | Director of Human Resources | Failed to ensure criminal background checks and physicals completed prior to hire |
Inspection Report
Life Safety
Deficiencies: 6
Oct 6, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 10/06 and 10/07/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for Avant Rehabilitation and Care Center.
Findings
The facility was found noncompliant with several Life Safety Code requirements including fire-rated door enclosures, sprinkler system installation, portable fire extinguisher maintenance, smoke barrier door integrity, elevator emergency communication, and emergency generator remote stop station. Deficiencies were confirmed by observations and testing during the survey.
Severity Breakdown
SS=D: 2
SS=E: 3
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Fire rated exit access door next to a resident room failed to positively latch, compromising fire resistance. | SS=D |
| Sprinkler heads in multiple utility and storage rooms lacked escheon caps, risking sprinkler system activation failure. | SS=E |
| One of sixteen portable fire extinguishers lacked documented monthly visual inspection; one extinguisher was mounted too high; one extinguisher was inoperative with discharge gauge in red zone. | SS=D |
| Three sets of corridor smoke barrier doors failed to close properly or had excessive gaps, allowing smoke transfer. | SS=F |
| Elevator emergency telephones in 2 of 3 elevators were not functioning. | SS=E |
| Emergency generator lacked a remote manual stop station as required. | SS=E |
Report Facts
Fire extinguishers inspected: 16
Smoke barrier doors tested: 7
Elevators in building: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present during observations and confirmed deficiencies related to fire doors, sprinkler heads, smoke doors, and emergency generator. | |
| Administrator | Notified of deficiencies at Life Safety Code exit conference on 10/07/2022. | |
| Corporate Regional Maintenance | Present during elevator emergency telephone testing and confirmed deficiencies. |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Jul 8, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ141492, NJ141369, and NJ136322.
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 numbers NJ141492, NJ141369, and NJ136322 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 7
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Mar 9, 2021
Visit Reason
The inspection was conducted based on a complaint visit to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint visit.
Complaint Details
The visit was complaint-related and the facility was found to be in compliance with the requirements.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 4
Jan 26, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted due to concerns about the facility's compliance with infection control regulations related to COVID-19, specifically regarding identification and mitigation of residents exposed to COVID-19.
Findings
The facility failed to identify residents exposed to COVID-19 as persons under investigation (PUI) and did not implement appropriate transmission-based precautions, posing a serious and immediate threat to resident safety. The facility lacked policies for contact tracing and exposure risk assessment, and staff were not consistently using or aware of proper PPE protocols. Hand hygiene practices by housekeeping staff were inadequate, increasing infection risk. The Immediate Jeopardy was removed after the facility implemented a removal plan including contact tracing, resident isolation, staff training, and PPE availability.
Complaint Details
The visit was complaint-related due to concerns about COVID-19 infection control practices. The Immediate Jeopardy was identified on 1/22/21 related to failure to implement proper COVID-19 mitigation strategies and was removed on 1/25/21 after corrective actions.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to identify residents exposed to COVID-19 as persons under investigation and implement transmission-based precautions. | Immediate Jeopardy |
| Lack of policy and procedure for contact tracing and exposure risk assessment. | — |
| Inadequate hand hygiene and glove use by housekeeping staff, including failure to change gloves between rooms and failure to perform hand hygiene. | — |
| Staff wearing surgical mask under KN95 mask instead of over it, contrary to infection control guidance. | — |
Report Facts
Census: 89
Exposure period: 48
Isolation duration: 14
Immediate Jeopardy notification time: 2021-01-22T15:28
Immediate Jeopardy removal time: 2021-01-25T10:54
Staff observed for PPE compliance: 5
Staff observed for PPE compliance follow-up: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #1) | Staff member who tested positive for COVID-19 and whose exposure triggered the investigation. | |
| Director of Nursing (DON) | Interviewed regarding infection control practices and policies. | |
| Assistant Director of Nursing/Infection Preventionist (ADON/IP) | Interviewed regarding infection control practices and policies. | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding facility policies and communication with local health department. | |
| Housekeeper | Observed failing to perform proper hand hygiene and glove changes between rooms. | |
| Certified Nursing Assistant (CNA) | Observed wearing surgical mask under KN95 mask and confirmed PPE training. |
Inspection Report
Routine
Census: 93
Deficiencies: 0
Nov 16, 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 and recommended practices 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 for COVID-19.
Report Facts
Sample size: 8
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