Inspection Reports for
Clover Rest Home
28 Washington Street, Columbia, NJ, 07832
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% better than New Jersey average
New Jersey average: 5.2 deficiencies/year
Deficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
100% occupied
Based on a January 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: 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 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 | NJDHSS Privacy Officer named as contact person for privacy practices |
Inspection Report
Routine
Deficiencies: 1
Date: May 7, 2025
Visit Reason
The inspection was conducted to assess compliance with infection control measures related to respiratory care, specifically the proper storage and handling of oxygen tubing for residents receiving oxygen therapy.
Findings
The facility failed to ensure that oxygen tubing was stored according to infection control standards, as observed with one resident whose oxygen tubing was found hanging off a portable oxygen tank and touching the floor. Staff acknowledged the tubing should not have been placed in a bag after touching the floor but discarded and replaced instead.
Deficiencies (1)
Oxygen tubing was stored improperly, hanging off the oxygen tank and touching the floor, not stored in a bag, posing infection control risks.
Report Facts
Residents affected: 1
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Interviewed regarding improper oxygen tubing storage | |
| Director of Nursing (DON) | Discussed findings and confirmed tubing should have been discarded | |
| Administrator and Assistant Administrator | Met with survey team to discuss observations |
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 12
Date: Jan 26, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint NJ00163064 triggered the recertification survey.
Findings
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.
Deficiencies (12)
Failed to accurately code the Minimum Data Set (MDS) for Resident #8.
Failed to follow professional standards by not acquiring physician's orders, not administering medication as ordered, and not following medication administration policy for Residents #19, #5, and #127.
Failed to ensure a Registered Nurse was present at the facility 7 days a week for at least 8 consecutive hours a day for 4 of 14 days reviewed.
Failed to maintain proper kitchen sanitation practices; microwave and air conditioning unit grills were dirty.
Failed to provide at least 80 square feet per resident bed in multi-bedded rooms or 100 square feet in single bedded rooms.
Building exceeded the two story height requirement for Type IV wood-frame structures with a sprinkler system.
Corridor width less than required 4 feet in exit access corridor next to kitchen measured 39 inches.
Failed to provide one illuminated exit sign to clearly identify the exit access path to reach an exit discharge door.
Portable fire extinguishers were mounted too high, exceeding the maximum allowed height.
Corridor doors failed to resist passage of smoke due to excessive gaps or undercuts.
One electrical outlet near a water source was not equipped with Ground-Fault Circuit Interrupter (GFCI) protection as required.
Failed to document emergency generator transfer time within required 10 seconds and lacked a remote manual stop station for the emergency generator.
Report Facts
Census: 33
Deficiencies cited: 12
Room size measurements: 61
Room size measurements: 91
Room size measurements: 39
Fire extinguisher mounting height: 63
Emergency generator transfer time: 4
Emergency generator transfer time: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 26, 2024
Visit Reason
The inspection was conducted due to a complaint (NJ #: 163054) regarding the facility's failure to ensure that a registered nurse was present for at least 8 consecutive hours a day, 7 days a week.
Complaint Details
Complaint NJ #: 163054. The complaint was substantiated based on review of Nurse Staffing Reports and interviews confirming lack of RN coverage on specified days.
Findings
The facility failed to have a registered nurse on duty for at least 8 consecutive hours daily on multiple days reviewed, including no RN coverage on 3/12/23, 3/18/23, 3/19/23, and 1/15/24. The Director of Nursing acknowledged the requirement for daily RN coverage.
Deficiencies (1)
Failure to ensure a registered nurse was present at the facility 7 days a week for at least 8 consecutive hours a day for 4 of 14 days reviewed.
Report Facts
Days without RN coverage: 4
Days reviewed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and acknowledged the requirement for RN coverage; stated she was previously the only RN employed. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 26, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding inaccurate Minimum Data Set (MDS) coding, failure to follow professional standards in medication and oxygen administration, inadequate nurse staffing, improper kitchen sanitation, and insufficient resident room space.
Complaint Details
Complaint NJ #: 163054. The complaint involved failure to ensure required RN coverage for 8 consecutive hours daily on multiple days. The Director of Nursing acknowledged the deficiency and that she was previously the only RN employed by the facility.
Findings
The facility was found deficient in accurately coding MDS assessments, administering oxygen and medications without proper physician orders or certified staff, failing to ensure required RN coverage for 8 consecutive hours daily, maintaining poor kitchen sanitation, and providing resident rooms with less than the required square footage per bed.
Deficiencies (5)
Failure to accurately code the Minimum Data Set (MDS) for Resident #8, incorrectly documenting an indwelling catheter when none was present.
Failure to follow professional standards by not acquiring physician's order for oxygen administration to Resident #19, administering medication incorrectly to Resident #5, and allowing non-IV certified LPNs to administer PICC line medications to Resident #127.
Failure to ensure a Registered Nurse was present for at least 8 consecutive hours daily on 4 of 14 days reviewed.
Failure to maintain proper kitchen sanitation, including unclean microwave and air conditioning units with heavy dust buildup.
Failure to provide resident rooms with at least 80 square feet per bed in multi-bedded rooms and 100 square feet in single rooms, with multiple rooms measuring significantly less.
Report Facts
Residents reviewed: 15
Days without RN coverage: 4
Square footage per resident bed: 47.5
Square footage per resident bed: 91.54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding MDS coding errors, oxygen administration, medication administration, and nurse staffing deficiencies | |
| Licensed Nursing Home Administrator | Informed of deficiencies and acknowledged concerns regarding MDS coding and kitchen sanitation | |
| LPN #1 | Licensed Practical Nurse | Interviewed about oxygen administration documentation for Resident #19 |
| LPN #2 | Licensed Practical Nurse | Observed administering medication incorrectly to Resident #5 and Resident #127 |
| Food Service Director | Interviewed regarding kitchen sanitation deficiencies | |
| Maintenance Director | Interviewed regarding cleaning schedule and maintenance of air conditioning units |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Jan 25, 2023
Visit Reason
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.
Complaint Details
Complaint NJ152146 triggered the survey. The facility was found not in substantial compliance based on this complaint survey.
Findings
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.
Deficiencies (1)
Failure to reassess and provide care for pressure ulcers consistent with professional standards for 1 of 3 residents reviewed.
Report Facts
Census: 33
Deficiency completion date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Named in relation to findings on pressure ulcer care and documentation |
| Nurse Practitioner | NP | Interviewed post-survey regarding treatment orders for pressure ulcers |
| License Practical Nurse | LPN | Interviewed regarding nursing responsibilities for wound care documentation |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Jul 15, 2022
Visit Reason
A complaint-related survey was conducted to assess compliance with New Jersey staffing regulations and minimum direct care staff-to-resident ratios.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Census: 31
Deficient CNA staffing days: 3
Required CNAs on day shift: 4
Actual CNAs on day shift: 2
Actual CNAs on day shift: 3
Deficient total staff days: 3
Correction completion date: Jul 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Discussed staffing ratio concerns with surveyor on 7/15/22. |
Inspection Report
Routine
Census: 31
Deficiencies: 0
Date: Dec 20, 2021
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.
Report Facts
Sample Size: 5
Inspection Report
Renewal
Census: 30
Deficiencies: 1
Date: Oct 22, 2021
Visit Reason
The visit was a Recertification Survey to assess compliance with New Jersey Administrative Code 8:39, Standards for Licensure of Long-Term Care Facilities.
Findings
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.
Deficiencies (1)
Failure to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law on six out of 14 day shifts reviewed.
Report Facts
Census: 30
Sample Size: 12
Deficiencies cited: 1
Staffing ratios: 3
Residents: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding staffing numbers and difficulties in hiring additional staff. |
| Administrator | Administrator | Interviewed regarding recruitment efforts and staffing challenges during the pandemic. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Oct 22, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning, nephrostomy tube care, and room size requirements as part of a regulatory survey.
Findings
The facility failed to develop and implement comprehensive care plans for residents with diabetes and nephrostomy tubes, and failed to provide resident rooms with the required minimum square footage per bed.
Deficiencies (3)
Failed to develop a comprehensive care plan with interventions for type two diabetes mellitus for one resident.
Failed to revise and update a care plan related to a nephrostomy tube for one resident.
Failed to provide rooms that are at least 80 square feet per resident bed in multi-bedded rooms.
Report Facts
Residents reviewed for care planning: 12
Care plan review date: 7
Room size measurements: 59.37
Room size measurements: 77
Room size measurements: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding care plan development and acknowledged failure to create diabetes care plan for Resident #27 | |
| Director of Nursing (DON) | Interviewed regarding importance of including diabetes and insulin administration in care plans | |
| Administrator | Interviewed regarding expectations for complete and accurate comprehensive care plans | |
| Maintenance Director | Confirmed room size measurements during facility tour |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
Date: Aug 3, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ143829, NJ143774, and NJ142374.
Complaint Details
Complaint numbers NJ143829, NJ143774, and NJ142374 were investigated and found to be without deficiencies.
Findings
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.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Date: Mar 5, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure appropriate transmission-based precautions and PPE use by healthcare staff for residents on PUI and isolation droplet precautions.
Report Facts
Census: 27
Sample size: 7
Immediate Jeopardy identification time: 1510
Completion date for Plan of Correction: 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Observed failing to wear appropriate PPE in PUI room and removed from duty. | |
| Occupational Therapist (OT) | Observed failing to wear full PPE in PUI room. | |
| Licensed Practical Nurse (LPN) | Observed failing to wear full PPE in PUI room. | |
| Director of Rehabilitation (DOR) | Observed failing to wear full PPE in PUI room and entering non-PUI rooms. | |
| Director of Nursing (DON) | Reported and managed Immediate Jeopardy, provided interviews and oversight. | |
| Medical Director (MD) | Provided policy interpretation and interview regarding PPE and quarantine orders. |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Date: Jan 13, 2021
Visit Reason
The inspection was conducted in response to complaint NJ 00142302 regarding infection prevention and control practices at the facility.
Complaint Details
Complaint #: NJ 00142302. The complaint was substantiated as the facility failed to enforce mask-wearing among residents, contrary to COVID-19 infection control requirements.
Findings
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.
Deficiencies (1)
Failure to establish and implement an infection prevention and control program to prevent the spread of infection, evidenced by residents not wearing face masks as required.
Report Facts
Census: 21
Sample Size: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed during the survey; unaware that residents could not walk outside their rooms without a facemask. |
| LPN #1 | Licensed Practical Nurse | Interviewed during the survey; stated residents did not have to wear a face mask outside their rooms. |
Inspection Report
Routine
Census: 20
Deficiencies: 0
Date: Dec 22, 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.
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: 10
Inspection Report
Abbreviated Survey
Census: 29
Deficiencies: 2
Date: Dec 3, 2020
Visit Reason
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.
Findings
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.
Deficiencies (2)
Failed to screen everyone upon entering the facility for symptoms of COVID-19 and failed to disinfect and sanitize the equipment used in the COVID-19 screening process.
Failed to ensure that workers were knowledgeable regarding the cleaning chemicals used in the workplace, including contact times, for 3 of 3 staff in accordance with CDC guidelines.
Report Facts
Census: 29
Sample size: 1
Completion date for plan of correction: Dec 5, 2020
Years worked: 11
Audit frequency: 2
Compliance target: 90
Audit duration: 4
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