Inspection Reports for Deptford Center For Rehabilitation And Healthcare

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The inspection was conducted as a complaint investigation based on multiple complaint numbers NJ184148, NJ184397, NJ184505, and NJ184757.

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.

Complaint numbers NJ184148, NJ184397, NJ184505, and NJ184757 were investigated and the facility was found to be in substantial compliance.

A Complaint Survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers listed in the report. The survey was to investigate allegations related to quality of care and staffing ratios at Deptford Center for Rehabilitation and Healthcare.

The facility was found not in substantial compliance with federal requirements, specifically failing to provide timely medical care and maintain required minimum staffing ratios. Deficiencies included failure to ensure residents received ordered outside appointments and inadequate Certified Nurse Aide staffing on certain shifts.

The complaint investigation was based on multiple complaint numbers from the New Jersey Department of Health. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B. The complaint was substantiated with findings related to quality of care and staffing deficiencies.

The inspection was conducted as a complaint investigation based on Complaint #: NJ00180466.

The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities and the New Jersey Administrative Code 8:39 standards for licensure of Long Term Care Facilities based on this complaint survey.

Complaint #: NJ00180466. The facility was found compliant based on this complaint survey.

A Complaint Survey was conducted on behalf of the New Jersey Department of Health from 05/20/2024 through 05/22/2024 to investigate multiple complaints regarding resident-to-resident abuse and failure to report investigation results timely.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long-term care facilities based on multiple resident-to-resident abuse incidents involving Resident 5 and others. Additionally, the facility failed to report the results of investigations to the State Survey Agency within five working days for 10 out of 13 sampled residents, potentially delaying corrective actions.

The complaint survey was triggered by multiple complaint numbers (NJ00163933, NJ00165261, NJ00165932, NJ00166156, NJ00166810, NJ00167718, NJ00167847, NJ00168002, NJ00168096, NJ00168350, NJ00168593, NJ00168955, NJ00170216, NJ00170526, NJ00170850, NJ00171428, NJ00171739, NJ00172429, NJ00172472, NJ00173828) alleging resident-to-resident abuse and failure to report investigation results timely. The facility was found not in substantial compliance based on these complaints.

Recertification survey and complaint investigations were conducted to determine compliance with federal and state regulations.

The facility was found deficient in multiple areas including emergency preparedness plan updates, resident dignity and rights, environmental cleanliness, resident care planning, medication administration, staffing levels, food service, infection control, and life safety code compliance. Corrective actions were implemented and verified during reinspection.

Complaint NJ00171057 involved allegations of insufficient nursing staff, delayed call bell response times, and cold food service. The complaint was substantiated with multiple deficiencies cited in staffing, resident care, and food service.

The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00164862, NJ00165456, NJ00168282, NJ00168313, NJ00168836.

The facility was found not in substantial compliance with federal and state regulations, with deficiencies identified in baseline and comprehensive care plans, treatment and services to prevent pressure ulcers, resident record confidentiality and documentation, and staffing levels. The facility failed to maintain required minimum direct care staff-to-resident ratios and timely reporting of incidents.

The complaint investigation involved multiple complaint numbers NJ00164862, NJ00165456, NJ00168282, NJ00168313, NJ00168836. The facility was found not in substantial compliance based on these complaints.

A complaint survey was conducted on behalf of the New Jersey Department of Health based on multiple complaint numbers from 06/11/2023 through 06/14/2023 to investigate staffing adequacy and compliance with state and federal regulations.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to insufficient nursing staff to meet resident needs, failing to maintain required minimum staff-to-resident ratios on multiple shifts, which potentially affected all residents. Staffing improvements and corrective actions were planned and later verified as corrected in a follow-up revisit.

The complaint investigation involved multiple complaint numbers including NJ00159266, NJ00159274, NJ159849, NJ00160010, NJ00160406, NJ00162765, NJ00163909, NJ00164203, and NJ00164267. The facility was found not in substantial compliance based on these complaints.

The inspection was conducted in response to a complaint (NJ159249) regarding the facility's failure to provide the correct therapeutic diet to a resident, resulting in harm and death.

The facility failed to provide the correct diet to Resident #2, who was cognitively impaired and on a prescribed puree nectar/mildly thick liquid diet. The resident was given a sandwich, which was not appropriate for the diet order, leading to choking and death. The facility also failed to notify the resident's physician and responsible party timely, and failed to report the incident to the state as required. Additionally, the facility did not implement a comprehensive care plan consistent with the resident's dietary needs and failed to educate staff adequately on diet orders and snack administration.

Complaint NJ159249 involved Resident #2 receiving the wrong diet (a sandwich instead of a puree nectar/mildly thick liquid diet), resulting in choking and death. The facility failed to notify the responsible party and physician timely and failed to report the incident to the NJ Department of Health within required timeframes.

An onsite revisit survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including complaint investigations and routine inspections.

The facility was found deficient in multiple areas including maintaining a safe, clean environment, reporting and investigating abuse allegations, completing significant change assessments and care plans, medication administration, food service operations, infection control, and life safety code compliance.

The inspection was conducted in response to complaints NJ152289, NJ152294, NJ152309, and NJ152310 regarding medication administration and pain management at Deptford Center for Rehabilitation and Healthcare.

The facility failed to administer medications according to physician's orders and maintain accurate medication administration documentation for 6 of 7 residents reviewed. The facility also failed to ensure adequate nursing staff coverage and to follow policies on pain management and medication administration documentation.

Complaint numbers NJ152289, NJ152294, NJ152309, and NJ152310 triggered the investigation. The complaints were substantiated as evidenced by medication administration errors and staffing deficiencies.

The inspection was conducted as a complaint survey based on complaints NJ149849 and NJ150192, focusing on infection control practices during the COVID-19 pandemic.

The facility was found not in compliance with infection control regulations, specifically failing to maintain an effective Infection Prevention and Control Program (IPCP). Deficiencies included lack of PPE and isolation signage outside resident rooms on isolation and staff failing to don PPE before entering isolation rooms for two residents.

The complaint survey was triggered by complaints NJ149849 and NJ150192. The facility was found not in compliance with 42 CFR §483.80 infection control regulations during the COVID-19 pandemic.

The inspection was conducted based on complaints NJ148957 and NJ149122 to investigate compliance with federal regulations regarding care planning, social services, and medical record documentation.

The facility was found not in substantial compliance due to failure to develop and implement comprehensive care plans for incontinence and discharge for 2 of 3 residents, failure to provide medically-related social services and discharge planning for 1 resident, and failure to document physician's orders for medications and treatments for 1 resident.

Complaint numbers NJ148957 and NJ149122 triggered the investigation. The facility was found not in substantial compliance based on these complaints.

The inspection was conducted as a complaint survey based on multiple complaint intakes (NJ145381, NJ146526, NJ146541, NJ145627) to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.

The facility failed to notify a responsible party when Resident #2 experienced a significant change in condition, despite provider notification and stat orders. Documentation lacked evidence of family/guardian notification. Licensed Practical Nurse #4 acknowledged the failure to notify, and the Director of Nursing confirmed the issue and remorse. The facility policy requires prompt notification of changes in resident condition to the resident, physician, and representative.

Complaint Intake NJ145381. The complaint was substantiated as the facility failed to notify the responsible party of Resident #2's change in condition.

The inspection was conducted as a complaint survey related to complaints NJ144639, NJ143125, and NJ145865.

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

Complaints NJ144639, NJ143125, and NJ145865 were investigated and the facility was found compliant.

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

The facility was found deficient in maintaining a safe, clean, and homelike environment, including failure to maintain cleanliness and sanitation in resident areas and wheelchairs. Additionally, deficiencies were noted in food procurement, storage, and preparation practices, including handling of dented cans, unlabeled frozen foods, and improper storage of sanitized equipment.

The inspection was conducted to assess the facility's compliance with Life Safety Code requirements, specifically focusing on fire safety and smoking regulations.

The facility was found not in substantial compliance with the Life Safety Code. Deficiencies included improperly positioned exhaust hood grease baffles in the kitchen, creating a fire hazard, and unsafe smoking practices in the designated smoking area with numerous extinguished cigarette butts littering the area, posing a fire risk.

The inspection was conducted based on complaints NJ131361 and NJ131059 to determine compliance with regulatory requirements.

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 the complaint survey.

Complaint numbers NJ131361 and NJ131059 were investigated and found to be unsubstantiated as the facility was in compliance.

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.

The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.