Inspection Reports for Clover Meadows Healthcare And Rehabilitation Cente
112 Franklin Corner Road, NJ, 08648
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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 NJDHSS's legal duties and responsibilities regarding 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 and contact person for privacy practices |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
Jun 3, 2024
Visit Reason
The inspection was conducted in response to complaint NJ173145 to investigate staffing ratio compliance at Clover Meadows Healthcare and Rehabilitation Center.
Findings
The facility was found to be out of compliance with New Jersey staffing ratio requirements, failing to meet minimum Certified Nurse Aide (CNA) staffing levels on 14 of 14 day shifts reviewed, potentially affecting all residents.
Complaint Details
Complaint #: NJ173145. The complaint was substantiated as the facility failed to maintain required minimum direct care staff-to-resident ratios on all day shifts reviewed.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 14 of 14-day shifts reviewed, not meeting minimum CNA staffing requirements as mandated by New Jersey law. |
Report Facts
CNA staffing deficiency days: 14
Census during staffing review: 90
Required CNAs per day shift: 12
Inspection Report
Routine
Census: 89
Capacity: 100
Deficiencies: 8
Oct 31, 2023
Visit Reason
Routine standard survey conducted on 10/31/2023 to assess compliance with federal and state regulations for long term care facilities, including complaint investigations and life safety code survey.
Findings
The facility was found not in substantial compliance with several regulatory requirements including resident rights, personal funds management, abuse investigation, transfer and discharge procedures, resident assessments, medication administration, infection control, and life safety code. Deficiencies were cited across multiple areas with corrective actions planned and completed by 12/13/2023.
Complaint Details
Complaint investigations were conducted for multiple complaint numbers including NJ00154446, NJ00152357, NJ00164964, NJ00167976, NJ00165907, and NJ00167863. Findings included failure to investigate abuse allegations, improper handling of resident funds, and inadequate privacy protections. Some complaints were substantiated as evidenced by cited deficiencies.
Severity Breakdown
Level D: 6
Level E: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to provide privacy and promote dignity during resident assessment and medication administration. | Level D |
| Failure to transfer discharged or expired resident personal funds within 30 days. | Level D |
| Failure to thoroughly investigate allegations of resident abuse. | Level D |
| Failure to follow policies and procedures for facility-initiated discharge. | Level D |
| Failure to accurately complete resident assessments and care plans. | Level D |
| Failure to properly label, store, and account for medications and controlled substances. | Level E |
| Failure to maintain fire alarm system and ensure proper egress door locking arrangements. | Level E |
| Failure to ensure emergency power generator has remote manual stop station. | Level E |
Report Facts
Census: 89
Total Capacity: 100
Deficiencies cited: 9
Completion Date: Dec 13, 2023
Inspection Report
Follow-Up
Census: 49
Deficiencies: 1
Aug 27, 2021
Visit Reason
The visit was conducted to assess compliance with New Jersey staffing regulations and to follow up on previously identified deficiencies related to minimum direct care staff-to-resident ratios.
Findings
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by New Jersey law, with documented staffing shortages on multiple shifts in August 2021. The facility acknowledged the staffing shortage and described corrective actions including use of agency staff, sign-on bonuses, and recruitment efforts.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. |
Report Facts
Census: 49
Deficiency dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) Unit Manager | Confirmed census and staffing pattern during interview on 8/26/2021 | |
| Staffing Coordinator | Acknowledged staffing shortage and use of agency staff during interview on 8/26/2021 | |
| Administrator | Stated staffing was short everywhere and use of agency staff during interview on 8/26/2021 |
Inspection Report
Routine
Census: 71
Deficiencies: 0
Dec 15, 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 COVID-19 practices.
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
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Dec 3, 2020
Visit Reason
The inspection visit was conducted in response to complaint #NJ141486 to assess compliance with regulatory requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, based on this complaint visit.
Complaint Details
Complaint #NJ141486 was investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 4
Report
Oct 15, 2024
File
20241015-COMPLAINT-VOB411.pdf
Report
Apr 19, 2021
File
20210419-ROUTINE-0K5511.pdf
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