Inspection Reports for
Clover Meadows Healthcare And Rehabilitation Cente

Complaint #2581082 was substantiated based on observation, interview, medical record review, and other documentation showing failure to update the care plan after identification of a skin impairment.

The facility failed to update or revise Resident #1's care plan to reflect a newly identified skin impairment (a blister) and corresponding treatment interventions despite documentation and initiation of treatment. The Director of Nursing confirmed the care plan should have been updated.

The facility was found deficient in ensuring physician orders for respiratory machines were in place and properly followed, adjusting medication administration times to accommodate dialysis schedules, and posting nurse staffing reports daily. Respiratory equipment was not properly maintained or stored, dialysis medication schedules were not properly managed, and nurse staffing reports were not updated daily.

Complaint # NJ00179885 involved an allegation by Resident #82 that a night nurse slapped them and shut off their oxygen. The facility reported the incident to NJDOH more than six hours after the event. The allegation was investigated and found not substantiated as the resident recanted the accusation after hospital return.

The facility failed to report an allegation of abuse involving Resident #82 within the mandated two-hour timeframe, reporting it more than six hours after the incident. The investigation concluded that the allegation was not substantiated, as the resident later stated the accusation was false after returning from the hospital.

Complaint #: NJ00172782, NJ00176379. The facility was found deficient in CNA staffing for residents on multiple day shifts during the periods 03/31/2024 to 04/13/2024, 08/11/2024 to 08/24/2024, and 09/15/2024 to 09/28/2024. The complaint was substantiated with findings of noncompliance.

The facility was found not in compliance with New Jersey Administrative Code 8:39 standards for licensure of Long Term Care Facilities due to failure to maintain required minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on multiple day shifts over several periods in 2024. The facility must submit a Plan of Correction to address these deficiencies.

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.

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 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.

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.

The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy during assessments and medication administration, failure to properly manage resident funds, inadequate investigation of resident-to-resident abuse, failure to complete timely and accurate resident assessments, improper handling of resident discharges, inaccurate medication documentation, incomplete narcotic shift counts, improper medication storage and labeling, food safety violations, and lapses in infection control practices.

Complaint #NJ00167863 involved failure to investigate resident to resident abuse. Complaint #NJ00151166 involved failure to follow discharge policies for Resident #243. Complaint #NJ00165907 involved CNA cutting resident's hair outside job description.

The facility failed to thoroughly investigate resident to resident abuse incidents involving Residents #52 and #64, failed to follow policies for a facility-initiated discharge of Resident #243, and allowed a Certified Nursing Assistant to cut a resident's hair, which was outside the CNA job description.

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.

The complaint investigation found that Resident #21 did not receive the prescribed frequency of Artificial Tears eye drops due to transcription errors and lack of communication of the eye doctor's consult recommendations. The issue was substantiated with documentation and interviews confirming the failure in medication administration and order transcription.

The facility failed to follow acceptable clinical standards by not properly transcribing and implementing physician orders for Artificial Tears eye drops for Resident #21, resulting in the resident receiving only one dose instead of the prescribed four times daily for five days. The nurse incorrectly transcribed the order without a stop date, and the facility lacked documentation that the eye doctor's consult recommendations were conveyed to staff.

Complaint# NJ 144728. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, based on this complaint visit related to infection prevention and control.

The facility was found not in substantial compliance with infection prevention and control requirements, specifically failing to ensure residents wore face masks in common areas and staff wore appropriate PPE during care for a resident on isolation precautions due to COVID-19 exposure.