Inspection Reports for Crystal Lake Healthcare And Rehabilitation
395 Lakeside Blvd, Bayville, NJ, 08721
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies. Earlier inspections showed a pattern of deficiencies primarily related to abuse prevention, staffing levels, and quality assurance, with several instances of immediate jeopardy that were later removed following corrective actions. Complaint investigations substantiated issues including failure to prevent and report abuse, inadequate staffing, and resident rights violations, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaints were substantiated, particularly those involving abuse and staffing concerns. The facility’s record shows some improvement over time, with the most recent inspection free of deficiencies after previous corrective efforts.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
127% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy 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, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 192
Capacity: 192
Deficiencies: 5
Date: Apr 29, 2025
Visit Reason
The inspection was conducted based on complaints NJ182091 and NJ185153 to investigate allegations of abuse, neglect, and staffing deficiencies at Crystal Lake Healthcare and Rehabilitation.
Complaint Details
Complaint numbers NJ182091 and NJ185153 were investigated. The facility was found not in substantial compliance with requirements related to abuse, neglect, and staffing. Immediate jeopardy was identified and later removed after corrective actions. The complaint was substantiated based on interviews, medical record reviews, and facility documentation.
Findings
The facility was found not in substantial compliance with federal requirements related to abuse, neglect, and staffing. Deficiencies included failure to immediately report and protect residents from observed abuse, inadequate staffing levels, and failure to maintain a quality assurance and performance improvement program. Immediate jeopardy was identified but later removed after corrective actions.
Deficiencies (5)
Failure to immediately report and protect residents from observed abuse and neglect, placing all residents in immediate jeopardy.
Failure to ensure staff implemented facility policies and procedures to provide care and services to achieve residents' highest practical wellbeing.
Failure to ensure facility hiring and use of nurse aides met regulatory requirements.
Failure to maintain adequate staffing levels as required by state regulations.
Failure to maintain an effective Quality Assurance and Performance Improvement (QAPI) program.
Report Facts
Census: 192
Total Capacity: 192
Sample Size: 5
Certified Nurse Aides (CNAs): 16
Required Staffing Hours: 484
Actual Staffing Hours: 480
Inspection Report
Complaint Investigation
Census: 201
Deficiencies: 5
Date: Dec 30, 2024
Visit Reason
The inspection was conducted based on complaints NJ181767, NJ181768, and NJ181846 regarding allegations of abuse and failure to protect a resident at Crystal Lake Healthcare and Rehabilitation.
Complaint Details
The complaint investigation was substantiated. The facility failed to prevent abuse of Resident #1 by staff, failed to intervene and report the abuse, and violated resident privacy and confidentiality. Immediate jeopardy was identified and later removed after corrective actions.
Findings
The facility was found not in substantial compliance with federal requirements due to failure to prevent abuse of a resident, failure of staff to intervene and report the abuse, and failure to ensure resident privacy and confidentiality. The facility implemented a removal plan, staff education, and audits to address these issues. Immediate jeopardy was removed as of 12/26/2024.
Deficiencies (5)
Failure to prevent abuse of a resident and failure of staff to intervene and report the incident.
Failure to conduct a timely and thorough investigation of an allegation of witnessed abuse.
Failure to ensure resident privacy and confidentiality, including unauthorized recording and posting of a resident on social media.
Failure to report an allegation of witnessed abuse to the Department of Health and local authorities in a timely manner.
Failure to follow facility abuse policy and procedure regarding abuse reporting and intervention.
Report Facts
Census: 201
Sample Size: 7
Date Survey Completed: Dec 30, 2024
Date of Revisit: Jan 30, 2025
Inspection Report
Complaint Investigation
Census: 211
Capacity: 213
Deficiencies: 7
Date: Oct 29, 2024
Visit Reason
The inspection was conducted due to multiple complaints alleging abuse, neglect, and failure to follow facility policies at Crystal Lake Healthcare and Rehabilitation. The visit aimed to investigate these allegations and assess compliance with regulatory requirements.
Complaint Details
The complaint investigation was substantiated with findings of abuse and neglect involving Resident #1 and other residents. Immediate Jeopardy was identified on 10/22/2024 and removed on 10/29/2024 after the facility implemented a Removal Plan and corrective actions. Multiple staff members were terminated or disciplined, and the facility re-educated all staff on abuse policies and incident reporting.
Findings
The facility was found not in substantial compliance with requirements related to abuse, neglect, and care plan implementation. Deficiencies included failure to prevent abuse, conduct timely investigations, implement care plans, and maintain adequate staffing levels. Immediate jeopardy was identified but later removed after corrective actions. The facility implemented a Removal Plan, re-educated staff, and initiated audits to monitor compliance.
Deficiencies (7)
Failure to provide services necessary to prevent abuse for a resident with a known history of aggressive behavior towards others.
Failure to conduct a timely and thorough investigation of witnessed and reported abuse allegations.
Failure to implement care plan interventions for a resident with a known history of aggressive behavior towards others.
Failure to follow facility policies titled 'Abuse Policy and Procedure' and 'Certified Nursing Assistant Job Description'.
Failure to ensure staffing ratios met minimum requirements for nursing staff on multiple days.
Failure to conduct and document investigations of alleged abuse incidents in a timely and thorough manner.
Failure to update care plans timely and implement interventions for residents.
Report Facts
Census: 211
Total Capacity: 213
Sample Size: 7
Staffing Deficiencies: 14
Staffing Deficiencies: 6
Required RN Staffing Hours: 546.75
Actual RN Staffing Hours: 536
Required RN Staffing Hours: 541.75
Actual RN Staffing Hours: 528
Inspection Report
Complaint Investigation
Census: 208
Deficiencies: 1
Date: Jun 25, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaint numbers NJ00172152, NJ00173597, and NJ00173806 to assess compliance with federal and state regulations for long term care facilities.
Complaint Details
Complaint investigation based on complaints NJ00172152, NJ00173597, and NJ00173806. The facility was found not in compliance with New Jersey Administrative Code Chapter 8:39 for licensure of long term care facilities due to staffing deficiencies. The facility was required to submit and implement a plan of correction.
Findings
The facility was found to be in substantial compliance overall but was cited for failure to meet required minimum staffing ratios on multiple day and overnight shifts, violating New Jersey staffing regulations. The facility implemented a multifaceted corrective plan including staff in-service, recruitment efforts, audits, and ongoing monitoring.
Deficiencies (1)
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 3 of 14 day shifts and 5 of 14 overnight shifts.
Report Facts
Census: 208
Deficient day shifts: 14
Deficient day shifts: 14
Deficient day shifts: 3
Deficient overnight shifts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to staffing deficiencies and corrective actions | |
| Staffing Coordinator | Named in relation to staffing deficiencies and corrective actions | |
| Human Resource Director | Named in relation to staffing deficiencies and corrective actions | |
| Administrator | Named in relation to staffing deficiencies and corrective actions |
Inspection Report
Complaint Investigation
Census: 217
Deficiencies: 1
Date: Apr 4, 2024
Visit Reason
The inspection was conducted based on a complaint survey (Complaint #: NJ172203) to investigate the facility's compliance with resident rights related to communication and possession of personal cell phones.
Complaint Details
Complaint #: NJ172203. The complaint involved the facility failing to honor the rights of Resident #1 to possess a personal cell phone. The complaint was substantiated based on interviews, record review, and policy review.
Findings
The facility failed to honor the rights of one resident to have a personal cell phone in their possession, as the resident's phone was taken away due to frequent 911 calls. The facility acknowledged the deficiency and implemented corrective actions including staff education and audits to ensure compliance with resident rights.
Deficiencies (1)
Failure to honor the rights of a resident to have a personal cell phone in their possession, restricting reasonable access to communication.
Report Facts
Census: 217
Sample Size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Social Worker | Acknowledged taking Resident #1's cell phone and keeping it in the social services office |
| Certified Nurse Aide #2 | Certified Nurse Aide | Assisted Resident #1 to use the telephone at the nurses' station and had not observed the resident with a cell phone |
| Director of Nursing | Director of Nursing | Explained the reason for taking Resident #1's cell phone and acknowledged lack of policy on cell phone use |
| Administrator | Administrator | Stated the facility would not take away Resident #1's cell phone going forward and would educate the resident not to dial 911 |
Inspection Report
Complaint Investigation
Census: 218
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
The inspection was conducted in response to complaint number 172038 to assess compliance with regulatory requirements.
Complaint Details
Complaint number 172038 was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Annual Inspection
Census: 214
Capacity: 219
Deficiencies: 12
Date: Feb 8, 2024
Visit Reason
Recertification and Complaint Survey conducted by Healthcare Management Solutions, LLC on behalf of New Jersey Department of Health (NJDOH) from 02/05/24 through 02/08/24, including complaint investigations.
Complaint Details
Complaint numbers NJ164067, NJ166370, NJ166770, NJ169235, NJ170803 triggered the survey. The facility was found not in substantial compliance based on these complaints.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including resident dignity, privacy, abuse prevention, complaint reporting, quarterly assessments, PASARR coordination, advance directives, respiratory care, bedrail use, infection control, and staffing ratios. Deficiencies included failure to maintain dignity during meal assistance, privacy breaches, inadequate abuse investigations and reporting, late quarterly MDS submissions, missing PASARR documentation, incomplete advance directives, unclean respiratory equipment, improper bedrail use, and infection control lapses during medication administration and meal assistance.
Deficiencies (12)
Failure to provide care and services in a manner that maintained and promoted dignity during meal assistance; staff stood while assisting residents with meals.
Failure to ensure resident privacy; medication cart computer screen left open revealing resident medications.
Failure to ensure residents were free from physical and sexual abuse; multiple incidents of resident-to-resident abuse with inadequate follow-up.
Failure to report allegations of abuse and injury of unknown origin timely to the State Survey Agency.
Failure to thoroughly investigate allegations of abuse and injury of unknown origin; lack of documentation and staff/resident statements.
Failure to complete quarterly Minimum Data Set (MDS) assessments in a timely manner for 14 of 35 sampled residents.
Failure to ensure PASARR documentation was complete and updated after new illness diagnosis or significant change in status.
Failure to ensure medical records included accurate advance directives and physician orders for code status.
Failure to maintain cleanliness of oxygen concentrators and respiratory equipment for two residents.
Failure to attempt alternatives and complete quarterly assessments for continued use and safety of bedrails for one resident.
Failure to prevent potential spread of infection; nurses did not disinfect glucometer after use and failed to sanitize medication cart and bedside tables; CNA failed to sanitize hands between feeding residents.
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Survey Census: 214
Sample Size: 35
Minimum CNA staffing required: 27
Actual CNA staffing: 15
Days late for quarterly MDS submission: 88
BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN3 | Licensed Practical Nurse | Named in infection control deficiency for failing to disinfect glucometer and medication cart surfaces |
| CNA10 | Certified Nursing Assistant | Named in dignity and infection control deficiencies for standing while feeding residents and failing to sanitize hands between residents |
| LPN1 | Licensed Practical Nurse | Named in abuse investigation and infection control deficiencies |
| RN1 | Registered Nurse | Named in abuse investigation and infection control deficiencies |
| DON | Director of Nursing | Named in multiple findings including infection control, abuse investigations, PASARR, advance directives, and staffing |
| Administrator | Named in abuse investigations, PASARR, and staffing deficiencies | |
| SSD | Social Services Director | Named in PASARR and abuse investigation deficiencies |
| Housekeeper | Named in infection control deficiency for failure to clean oxygen concentrators | |
| Director of Therapy | Named in bedrail use deficiency for failure to attempt alternatives | |
| LPN6 | Licensed Practical Nurse | Named in infection control deficiency for cleaning responsibilities |
Inspection Report
Life Safety
Census: 213
Capacity: 248
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 02/07/24 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Findings
The facility was found to be in compliance with the Life Safety Code requirements and Medicare/Medicaid participation standards. No deficiencies were cited during this survey.
Report Facts
Occupied beds: 213
Total licensed capacity: 248
Inspection Report
Complaint Investigation
Census: 212
Deficiencies: 5
Date: Aug 18, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health covering multiple complaint numbers from 08/15/23 to 08/18/23.
Complaint Details
The complaint survey was triggered by multiple complaint numbers including NJ00165693, NJ00164145, NJ00164082, NJ00163445, NJ00162420, NJ00159225, NJ00157035, NJ00155008, NJ00154346, NJ00154159, NJ00153728, NJ00153625, NJ00153320, and NJ00151371. The facility was found not in substantial compliance based on these complaints.
Findings
The facility was found not in substantial compliance with federal requirements for long term care facilities based on multiple deficiencies including failure to notify resident representatives of condition changes, inaccurate assessments, medication ordering and administration issues, incomplete resident records, and failure to maintain required staffing ratios.
Deficiencies (5)
Failure to notify resident representative of significant change in resident's condition and hospital transfer.
Failure to ensure accuracy of resident assessments (Minimum Data Set).
Failure to provide timely medication orders and ensure availability for one resident.
Failure to maintain complete and accurate clinical records related to medication administration.
Failure to maintain required minimum staff-to-resident ratios as mandated by New Jersey law.
Report Facts
Survey Census: 212
Sample Size: 17
Staffing Deficiencies: 147
Staffing Deficiencies: 2
Staffing Deficiencies: 10
Inspection Report
Abbreviated Survey
Census: 222
Deficiencies: 0
Date: Dec 9, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health on 12/9/2022.
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
Routine
Census: 208
Deficiencies: 0
Date: Dec 29, 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 and CDC recommended 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 to prepare for COVID-19.
Inspection Report
Annual Inspection
Census: 197
Capacity: 235
Deficiencies: 20
Date: Oct 29, 2021
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 facility cleanliness, comprehensive assessments, care planning, medication monitoring, food safety, environmental safety, and life safety code compliance.
Deficiencies (20)
Facility failed to maintain a clean and sanitary environment in multiple units with soiled floors, peeling wallpaper, stained smoking area, and unclean equipment.
Facility failed to complete comprehensive Minimum Data Set assessments in a timely manner for 8 residents.
Facility failed to complete Quarterly Minimum Data Set assessments in a timely manner for 27 residents.
Facility failed to ensure accurate Minimum Data Set assessments for 2 residents, with incorrect coding of functional status and treatments.
Facility failed to ensure a comprehensive and accurate care plan for 1 resident, missing care plans for pain management.
Facility failed to monitor resident behaviors with psychotropic medication changes, failed to transcribe a physician order into EMR, and failed to complete neurological assessments after a fall for 2 residents.
Laundry room door on 7th floor was not locked, posing a safety hazard due to access to laundry chute.
Facility failed to obtain physician orders for oxygen therapy and failed to change oxygen tubing timely for 2 residents.
Multi-use insulin medications were not dated with opened dates on medication carts.
Facility failed to handle potentially hazardous foods and maintain sanitation in kitchen and pantries, including expired spices, dented cans, wet nesting pans, unclean meat slicer, inadequate sanitizer concentration, dirty equipment, and unlabeled or undated food items in refrigerators and pantries.
Facility failed to maintain the garbage container area free of garbage and debris.
Facility failed to maintain complete and accurate medical records for 2 residents, including incomplete admission assessments.
Facility failed to maintain stair thread marking stripes on all steps, landings, and handrails in all four stairwells.
Facility failed to provide battery backup emergency light above the emergency generator's transfer switch independent of building electrical system.
Facility failed to provide self-closing doors on hazardous areas including combustible storage rooms.
Facility failed to maintain sprinkler system by ensuring ceilings were smoke resistant and fire rated; missing ceiling tiles and escutcheon plates in multiple locations.
Facility failed to maintain adequate ventilation in 6 resident bathrooms and 1 shower room.
Facility failed to ensure elevators were inspected and tested monthly and failed to maintain emergency communication telephones in 2 of 3 elevators.
Facility failed to prohibit use of power strips for refrigerators and microwaves in nurses lounge and physical therapy room.
Facility failed to maintain required clearance around electrical panels, with mop bucket and wooden pole stored in front of panel.
Report Facts
Census: 197
Total Capacity: 235
Deficiencies cited: 14
Deficiencies cited: 3
Residents reviewed for comprehensive assessments: 78
Residents with late comprehensive assessments: 8
Residents reviewed for quarterly assessments: 78
Residents with late quarterly assessments: 27
Residents reviewed for MDS accuracy: 37
Residents with inaccurate MDS: 2
Residents reviewed for care planning: 37
Residents with deficient care plans: 1
Residents reviewed for psychotropic medication monitoring: 5
Residents with deficient psychotropic monitoring: 1
Residents reviewed for neurological assessments after fall: 1
Laundry room doors unlocked: 1
Residents reviewed for oxygen therapy: 2
Residents with missing oxygen orders or tubing dates: 2
Medication carts reviewed: 6
Medication carts with undated insulin: 2
Food safety violations: 10
Garbage container area violations: 1
Residents reviewed for medical record completeness: 35
Residents with incomplete admission assessments: 2
Stairwells without marking stripes: 4
Emergency lighting missing: 1
Hazardous area doors without self-closing devices: 1
Ceiling tiles missing or damaged: 27
Resident bathrooms with non-functioning ventilation: 6
Shower rooms with non-functioning ventilation: 1
Elevators without emergency communication: 2
Power strips used for refrigerators/microwaves: 2
Electrical panels with inadequate clearance: 1
Staffing deficient day shifts: 14
Staffing deficient night shifts: 3
Elevators not inspected monthly: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Verified refrigerator temperature monitoring responsibility and food storage observations |
| LPN #2 | Licensed Practical Nurse | Completed psychotropic medication change form for Resident #135 fall incident report |
| LPN #3 | Licensed Practical Nurse | Observed pantry food storage and refrigerator temperature logs |
| LPN #4 | Licensed Practical Nurse | Discussed oxygen orders and tubing change policy |
| LPN #5 | Licensed Practical Nurse | Reviewed psychotropic medication orders and monitoring forms for Resident #123 |
| LPN #6 | Licensed Practical Nurse | Reviewed Resident #736 medical record and care plan |
| LPN #7 | Licensed Practical Nurse | Commented on laundry room door lock status |
| LPN #8 | Licensed Practical Nurse | Provided key to laundry room door |
| CNA #1 | Certified Nursing Assistant | Reported laundry room door lock broken and maintenance rounds |
| CNA #2 | Certified Nursing Assistant | Reported laundry room door lock broken |
| CNA #3 | Certified Nursing Assistant | Used laundry chute door with new key lock |
| FSD | Food Service Director | Interviewed about kitchen sanitation and food storage |
| ADON | Assistant Director of Nursing | Interviewed about MDS assessments, oxygen orders, and medication labeling |
| DON | Director of Nursing | Interviewed about staffing, MDS assessments, oxygen orders, medication monitoring, and care planning |
| Maintenance Director | Maintenance Director | Interviewed about stairwell markings, emergency lighting, hazardous doors, sprinkler system, ventilation, elevator communication, electrical panel clearance |
| Administrator | Facility Administrator | Interviewed about laundry door lock policy, staffing, and facility policies |
| Regional Director of Clinical Operations | Regional Director of Clinical Operations | Interviewed about laundry door lock policy |
| Activities Director | Activities Director | Interviewed about smoking area cleanliness |
| Housekeeping Manager | Housekeeping Manager | Interviewed about cleaning responsibilities and smoking area |
| Smoking Monitor | Smoking Monitor | Interviewed about smoking area cleanliness |
Inspection Report
Complaint Investigation
Census: 188
Deficiencies: 2
Date: Aug 19, 2021
Visit Reason
The inspection was conducted based on Complaint # NJ 145922 regarding allegations of staff to resident abuse and failure to follow facility policies.
Complaint Details
Complaint # NJ 145922 involved allegations of staff to resident abuse for Resident #2. The facility failed to report the allegation timely to the Administration and NJDOH. The allegation was investigated but not confirmed. Education on Abuse & Neglect Policy was provided to involved staff and will continue monthly.
Findings
The facility was found not in substantial compliance due to failure to timely report an allegation of staff to resident abuse and failure to follow the facility's Abuse & Neglect policy for Resident #2. Additionally, the facility failed to provide proper care and follow the Feeding Tube-Site Care policy for Resident #1.
Deficiencies (2)
Failure to report timely an allegation of staff to resident abuse to the Administration and notify the New Jersey Department of Health as required.
Failure to provide proper care and follow the facility policy titled 'Feeding Tube-Site Care' for Resident #1.
Report Facts
Census: 188
Sample Size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Acting Nurse Supervisor | Named in failure to report allegation of abuse to Administration and NJDOH |
| LPN #2 | Reported allegation of abuse to LPN #1 | |
| CNA #1 | Certified Nursing Assistant | Accused of hitting Resident #2 and reported allegation to LPN #2 |
| CNA #2 | Certified Nursing Assistant | Assisted CNA #1 and informed LPN #2 of the allegation |
| Director of Nursing | DON | Reported protocol for feeding tube site care |
| Unit Manager | UM | Observed feeding tube site condition |
| Human Resource Director | Responsible for reporting education completeness during QAPI meetings |
Inspection Report
Complaint Investigation
Census: 172
Deficiencies: 0
Date: May 20, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint numbers NJ143135, NJ143441, NJ144410, and NJ145179.
Complaint Details
Complaint numbers NJ143135, NJ143441, NJ144410, and NJ145179 were investigated and the facility was found to be in compliance.
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 visit.
Report Facts
Sample Size: 5
Inspection Report
Complaint Investigation
Census: 154
Deficiencies: 1
Date: Jan 19, 2021
Visit Reason
The visit was a COVID-19 Focused Infection Control Survey conducted due to concerns about infection control practices related to COVID-19 exposure and transmission within the facility.
Complaint Details
The visit was complaint-related due to concerns about COVID-19 infection control failures, including failure to identify exposed residents as PUIs and failure to implement appropriate PPE and isolation protocols. Immediate Jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to identify all residents exposed to COVID-19 as persons under investigation (PUI) and did not implement appropriate transmission-based precautions (TBP), posing an immediate jeopardy to resident safety. Staff were not consistently using N95 masks or full PPE as required. The facility submitted removal plans and eventually complied with infection control requirements by 1/29/2021.
Deficiencies (1)
Failure to identify residents exposed to COVID-19 as persons under investigation (PUI) and failure to implement transmission-based precautions (TBP) to prevent spread of COVID-19.
Report Facts
Census: 154
Sample size: 91
Removal Plan Completion Date: 2021
Number of N95 masks: 5704
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Tested positive for COVID-19 and worked multiple shifts on affected floors; responsible for resident care. |
| HK #1 | Housekeeper | Tested positive for COVID-19; responsible for cleaning resident rooms on affected floors. |
| ADON/IP | Assistant Director of Nursing/Infection Preventionist | Provided information on infection control practices and facility response. |
| LNHA | Licensed Nursing Home Administrator | Communicated with local health department and responsible for non-nursing department supervision. |
| DON | Director of Nursing | Communicated with local health department and oversaw infection control measures. |
| HKD | Housekeeping Director | Responsible for housekeeping staff education and infection control compliance. |
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