Inspection Reports for Clover Rest Home

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A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

Deficiencies were cited related to accuracy of assessments, professional standards in care, nursing staffing, food safety, room size, and life safety code compliance including fire safety, corridor width, exit signage, fire extinguishers, corridor doors, electrical safety, and emergency generator maintenance.

Complaint NJ00163064 triggered the recertification survey.

The inspection was conducted based on a complaint survey (NJ152146) to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.

The facility was found not in substantial compliance due to failure to reassess and provide care consistent with professional standards for pressure ulcers for 1 of 3 residents reviewed. Deficiencies included lack of documentation and treatment for pressure ulcers, failure to obtain physician orders timely, and incomplete wound care documentation.

Complaint NJ152146 triggered the survey. The facility was found not in substantial compliance based on this complaint survey.

A complaint-related survey was conducted to assess compliance with New Jersey staffing regulations and minimum direct care staff-to-resident ratios.

The facility was found not in compliance with New Jersey staffing requirements, failing to maintain minimum direct care staff-to-resident ratios on multiple day shifts. Deficiencies in CNA staffing and total staff were documented, with corrective actions planned and discussed with the Director of Nursing.

The visit was complaint-related, focusing on staffing ratio concerns. The facility was found deficient in CNA staffing on 3 of 14 day shifts and deficient in total staff for residents on 3 of 14 day shifts. The Director of Nursing was informed of these concerns on 7/15/22.

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.

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.

The visit was a Recertification Survey to assess compliance with New Jersey Administrative Code 8:39, Standards for Licensure of Long-Term Care Facilities.

The facility was found not in substantial compliance due to failure to maintain required direct care staff-to-resident ratios on six out of 14 day shifts reviewed, potentially affecting all residents. The facility implemented corrective actions including increased CNA sign-on bonuses and monthly staffing audits.

The inspection was conducted as a complaint survey based on complaints NJ143829, NJ143774, and NJ142374.

The facility was found to be in compliance with the requirements of 42 CFR Part 483 B for Long Term Care Facilities based on this complaint survey.

Complaint numbers NJ143829, NJ143774, and NJ142374 were investigated and found to be without deficiencies.

The inspection was conducted based on a complaint (NJ143423) regarding failure to ensure appropriate transmission-based precautions and infection control practices related to COVID-19 for residents placed on Persons Under Investigation (PUI) and isolation droplet precautions.

The facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) according to CDC and state guidelines when caring for PUI residents, resulting in an Immediate Jeopardy situation. The facility also failed to properly identify and cohort residents, leading to potential COVID-19 transmission risks. A plan of correction was implemented and verified during a revisit.

Complaint NJ143423 was substantiated with an Immediate Jeopardy identified on 3/5/2021 due to staff not using appropriate PPE and improper cohorting of residents, posing a serious threat to resident safety. The facility provided an acceptable Immediate Jeopardy Removal Plan on the same day, which was verified on 3/9/2021.

The inspection was conducted in response to complaint NJ 00142302 regarding infection prevention and control practices at the facility.

The facility failed to establish and implement acceptable infection prevention and control standards to prevent the spread of infection, specifically related to residents not wearing face masks as required by COVID-19 source control guidelines. Nine of 21 residents were observed without face masks in various areas of the facility.

Complaint #: NJ 00142302. The complaint was substantiated as the facility failed to enforce mask-wearing among residents, contrary to COVID-19 infection control requirements.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.

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.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.

The facility was found not to be in compliance with infection control regulations, specifically failing to screen everyone upon entry for COVID-19 symptoms, failing to disinfect and sanitize screening equipment properly, and lacking staff knowledge regarding cleaning chemical contact times and proper use.