Inspection Reports for Deptford Center For Rehabilitation And Healthcare
1511 Clements Bridge Rd, Deptford, NJ, 08096
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 19, 2025, did not identify any deficiencies. Earlier inspections showed a mixed compliance history with deficiencies primarily related to staffing levels, resident care planning, medication administration, infection control, and food service operations. Several complaint investigations substantiated issues such as resident-to-resident abuse, failure to maintain minimum staffing ratios, missed medical appointments, and inadequate reporting of incidents. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection record shows some improvement over time, with recent surveys indicating better compliance compared to multiple earlier inspections that cited numerous deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
14.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
185% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
219 residents
Based on a March 2025 inspection.
Census over time
Notice
Deficiencies: 0
Date: Nov 19, 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 details 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 regarding the notice |
Inspection Report
Complaint Investigation
Census: 219
Deficiencies: 0
Date: Mar 26, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint numbers NJ184148, NJ184397, NJ184505, and NJ184757.
Complaint Details
Complaint numbers NJ184148, NJ184397, NJ184505, and NJ184757 were 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: 10
Inspection Report
Complaint Investigation
Census: 230
Deficiencies: 2
Date: Feb 26, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to ensure Resident 9 received scheduled outside medical appointments, leading to potential medical issues related to missed procedures.
Failure to maintain required minimum staff-to-resident ratios for Certified Nurse Aides on 1 of 14 day shifts during the complaint period.
Report Facts
Survey Census: 230
Sample Size: 22
Certified Nurse Aides (CNAs) on 02/22/25 day shift: 28
Deficiency Completion Date: 2025
Inspection Report
Complaint Investigation
Census: 212
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #: NJ00180466.
Complaint Details
Complaint #: NJ00180466. The facility was found compliant based on this complaint survey.
Findings
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.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 184
Deficiencies: 2
Date: May 22, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to ensure residents were free from verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion, specifically resident-to-resident abuse involving multiple residents.
Failure to report the results of investigations to the State Survey Agency within five working days as required by regulation.
Report Facts
Complaint numbers: 20
Survey census: 184
Sample size: 31
Residents with delayed reporting: 10
Residents sampled: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Named in investigation report related to resident R3's abuse allegation |
| CNA 3 | Certified Nursing Assistant | Named in investigation report related to resident R4's abuse allegation |
| CNA 13 | Certified Nursing Assistant | Interviewed regarding resident R5's history of aggressive behavior |
| CNA 14 | Certified Nursing Assistant | Interviewed regarding resident R5's behavior |
| Unit Manager 1 | Unit Manager | Interviewed regarding resident R5's history of resident-to-resident incidents |
Inspection Report
Re-Inspection
Census: 211
Capacity: 207
Deficiencies: 26
Date: Mar 5, 2024
Visit Reason
Recertification survey and complaint investigations were conducted to determine compliance with federal and state regulations.
Complaint Details
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.
Findings
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.
Deficiencies (26)
Failed to ensure emergency preparedness plan was reviewed and updated annually and sent to local emergency management.
Failed to ensure resident dignity and rights, including appropriate clothing and transport, and access to survey results.
Failed to protect confidentiality of resident medical records; medication administration record left open and visible.
Failed to maintain a safe, clean, comfortable, and homelike environment including dining experience and sanitation of equipment and environment.
Failed to accurately complete PASARR screening for newly admitted resident.
Failed to develop and implement comprehensive person-centered care plans reflecting resident medical and psychosocial needs.
Failed to update care plan timely after hospitalization and change in condition.
Failed to provide care and services consistent with professional standards, including medication administration and oxygen therapy.
Failed to ensure residents with limited range of motion received prescribed treatments to prevent decline.
Failed to maintain continence care and catheter care consistent with standards.
Failed to provide respiratory care including tracheostomy care and suctioning consistent with standards.
Failed to maintain sufficient nursing staff to provide care to residents on a 24-hour basis.
Used non-certified nursing aides beyond allowed 120 days without competency evaluation.
Failed to maintain accountability and documentation of controlled medications including narcotic shift count logs.
Failed to properly label and store medications and secure treatment carts when unattended.
Failed to provide all items on corporate menu and serve food at safe and appetizing temperatures.
Failed to accommodate resident allergies, intolerances, and preferences accurately.
Failed to procure, store, prepare, and serve food in accordance with professional food safety standards including sanitation and labeling.
Failed to implement infection prevention and control program including proper PPE use, hand hygiene, and infection control practices during care and dining.
Failed to provide continuous illumination of means of egress at exit discharge doors.
Failed to maintain vertical openings enclosure with 2-hour fire rated doors.
Failed to maintain hazardous areas enclosure with 1-hour fire rated doors or automatic fire extinguishing system.
Failed to maintain corridor doors with positive latching hardware and smoke resistance; roller latches prohibited but found.
Failed to maintain smoke barrier doors to resist transfer of smoke with gaps exceeding allowable clearance.
Failed to maintain electrical outlets near water sources with required ground-fault circuit interrupter (GFCI) protection.
Failed to maintain emergency communication in proper working condition for elevators and failed to have annual elevator inspections current.
Report Facts
Resident census: 211
Total licensed capacity: 207
Deficiency counts: 25
Staffing ratios: 1
Staffing ratios: 1
Staffing ratios: 1
Medication administration omissions: 4
Temperature readings: 182
Temperature readings: 130.8
Temperature readings: 101.5
Temperature readings: 98.4
Temperature readings: 155
Temperature readings: 54.5
Elevator inspection overdue: 17
Nursing aide employment duration: 120
Medication refrigerator temperature: 27
Medication refrigerator temperature: 35
Electrical outlet gap: 1.25
Electrical outlet gap: 2.5
Electrical outlet gap: 0.375
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed about care plan process and medication administration |
| LPN #2 | Licensed Practical Nurse | Interviewed about medication cart and treatment cart use |
| LPN #3 | Licensed Practical Nurse | Interviewed about medication cart cleanliness and labeling |
| LPN #4 | Licensed Practical Nurse | Interviewed about narcotic shift count logs and medication cart organization |
| LPN #5 | Licensed Practical Nurse | Interviewed about medication administration record confidentiality |
| LPN/UM #1 | Licensed Practical Nurse/Unit Manager | Interviewed about care plan process and suction machine storage |
| LPN/UM #2 | Licensed Practical Nurse/Unit Manager | Interviewed about care plan process and catheter care |
| CNA #1 | Certified Nursing Assistant | Observed transporting resident undignified manner |
| CNA #2 | Certified Nursing Assistant | Interviewed about resident care and clothing |
| CNA #3 | Certified Nursing Assistant | Interviewed about infection control and treatment assistance |
| CNA #4 | Certified Nursing Assistant | Interviewed about meal tray service |
| CNA #5 | Certified Nursing Assistant | Interviewed about resident care and infection control |
| Dietary Aid #1 | Dietary Aid | Interviewed about meal ticket preparation and food service |
| Dietary Aid #2 | Dietary Aid | Interviewed about meal ticket review and food service |
| Dietary Aid #3 | Dietary Aid | Interviewed about infection control and mask use in dining room |
| Director of Nursing | Director of Nursing | Interviewed about staffing and care plan oversight |
| Director of Maintenance | Director of Maintenance | Interviewed about fire safety and elevator repairs |
| Human Resources | Human Resources | Interviewed about employee reference checks |
| Licensed Nursing Home Administrator | LNHA | Interviewed about employee reference checks and staffing |
| Regional Administrator | Regional Administrator | Provided education on PASARR and staffing |
| Social Worker | Director of Social Work | Interviewed about PASARR and grievance process |
| Surveyor #1 | State Surveyor | Conducted interviews and observations |
| Surveyor #2 | State Surveyor | Conducted interviews and observations |
| Surveyor #3 | State Surveyor | Conducted interviews and observations |
Inspection Report
Complaint Investigation
Census: 200
Deficiencies: 6
Date: Nov 9, 2023
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00164862, NJ00165456, NJ00168282, NJ00168313, NJ00168836.
Complaint Details
The complaint investigation involved multiple complaint numbers NJ00164862, NJ00165456, NJ00168282, NJ00168313, NJ00168836. The facility was found not in substantial compliance based on these complaints.
Findings
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.
Deficiencies (6)
Failure to develop a baseline care plan for a newly admitted resident within 48 hours of admission.
Failure to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes.
Failure to provide treatment and services to prevent pressure ulcers and promote healing.
Failure to maintain complete, accurate, and confidential resident medical records and documentation of Activities of Daily Living (ADL).
Failure to maintain required minimum direct care staff-to-resident ratios for Certified Nursing Assistants (CNAs) and total staff on day, evening, and night shifts.
Failure to notify the Department of Health within 72 hours of certain incidents as required.
Report Facts
Census: 200
Sample Size: 5
Staffing Deficiencies: 14
Staffing Deficiencies: 28
Staffing Deficiencies: 4
Staffing Deficiencies: 7
Staffing Deficiencies: 15
Audit Frequency: 20
Audit Frequency: 4
Audit Frequency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Named in relation to findings on care plan updates, incident reporting, and staffing audits. | |
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding resident care and consent for searches, care treatment orders, and documentation. | |
| Certified Nursing Assistant (CNA) #1 | Interviewed regarding Activities of Daily Living (ADL) care and documentation. | |
| Assistant Director of Nursing (ADON) | Responsible for second day assessments and ensuring care plans and treatment orders are accurate and complete. | |
| Staff Educator/Designee | Educated nursing staff on baseline care plans, comprehensive care plans, treatment and services, and ADL documentation. | |
| Staffing Coordinator | Educated on maintaining adequate nursing staffing levels and presenting daily schedules to DON and Administrator. |
Inspection Report
Complaint Investigation
Census: 198
Deficiencies: 2
Date: Jun 11, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Facility failed to ensure sufficient nursing staff with appropriate competencies to meet resident needs and maintain safety.
Facility did not meet minimum staff-to-resident ratios as mandated by New Jersey for 13 of 14 day shifts, 2 of 14 evening shifts, and 3 of 14 overnight shifts.
Report Facts
Survey Census: 198
Sample Size: 11
Deficient day shifts: 13
Deficient evening shifts: 2
Deficient overnight shifts: 3
Resident census on specific dates: 205
Required CNAs on 05/28/23 day shift: 26
Actual CNAs on 05/28/23 day shift: 16
Required total staff on 05/28/23 evening shift: 20
Actual total staff on 05/28/23 evening shift: 18
Required CNAs on 05/29/23 day shift: 20
Actual CNAs on 05/29/23 day shift: 19
Required total staff on 05/29/23 evening shift: 20
Actual total staff on 05/29/23 evening shift: 19
Required CNAs on 05/30/23 day shift: 25
Actual CNAs on 05/30/23 day shift: 17
Required total staff on 05/30/23 overnight shift: 15
Actual total staff on 05/30/23 overnight shift: 14
Required CNAs on 05/31/23 day shift: 25
Actual CNAs on 05/31/23 day shift: 23
Required CNAs on 06/01/23 day shift: 25
Actual CNAs on 06/01/23 day shift: 21
Required CNAs on 06/02/23 day shift: 25
Actual CNAs on 06/02/23 day shift: 20
Required CNAs on 06/03/23 day shift: 25
Actual CNAs on 06/03/23 day shift: 21
Required total staff on 06/03/23 overnight shift: 14
Actual total staff on 06/03/23 overnight shift: 13
Required CNAs on 06/04/23 day shift: 24
Actual CNAs on 06/04/23 day shift: 19
Required CNAs on 06/05/23 day shift: 24
Actual CNAs on 06/05/23 day shift: 20
Required total staff on 06/05/23 overnight shift: 14
Actual total staff on 06/05/23 overnight shift: 12
Required CNAs on 06/06/23 day shift: 24
Actual CNAs on 06/06/23 day shift: 23
Required CNAs on 06/08/23 day shift: 25
Actual CNAs on 06/08/23 day shift: 20
Required CNAs on 06/09/23 day shift: 24
Actual CNAs on 06/09/23 day shift: 21
Required CNAs on 06/10/23 day shift: 24
Actual CNAs on 06/10/23 day shift: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 1 | Voiced concerns regarding insufficient staffing and workload during the complaint investigation. | |
| Director of Nursing | DON | Interviewed regarding staffing schedules, use of agency staff, and staffing improvements. |
| Administrator | Interviewed with DON about staffing and corrective actions. | |
| Licensed Practical Nurse 1 | LPN | Interviewed regarding staffing and workload. |
| Licensed Practical Nurse 2 | LPN | Interviewed regarding staffing and workload. |
| Licensed Practical Nurse 3 | LPN | Interviewed regarding staffing and workload. |
| Certified Nurse Aide 2 | CNA | Interviewed regarding staffing and workload. |
| Certified Nurse Aide 3 | CNA | Interviewed regarding staffing and workload. |
Inspection Report
Complaint Investigation
Census: 204
Deficiencies: 4
Date: Nov 7, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failure to provide the correct therapeutic diet to Resident #2, resulting in choking and death.
Failure to notify responsible party and physician of the incorrect diet served to Resident #2.
Failure to report the incident involving Resident #2 to the New Jersey Department of Health within required timeframes.
Failure to implement a comprehensive care plan for Resident #2 consistent with dietary needs.
Report Facts
Census: 204
Sample Size: 3
Deficiency Level D: 2
Deficiency Level J: 1
Deficiency Level G: 1
Date of Incident: Oct 25, 2022
Date of Survey Completion: Nov 7, 2022
Date of Revisit: Dec 30, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Gave Resident #2 a sandwich against diet order |
| LPN #1 | Licensed Practical Nurse | Approved sandwich for Resident #2 |
| LPN #2 | Licensed Practical Nurse | Responded to code blue and noted food in Resident #2's bed |
| Director of Nursing | Director of Nursing (DON) | Pronounced Resident #2's death and acknowledged failure to notify family and physician timely |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Provided education and acknowledged notification failures |
| Dietician | Dietician | Provided education on therapeutic diets and diet manual |
| Nurse Practitioner | Nurse Practitioner (NP) | Notified of Resident #2's death but not of the diet incident |
Inspection Report
Annual Inspection
Census: 212
Deficiencies: 20
Date: Sep 20, 2022
Visit Reason
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.
Findings
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.
Deficiencies (20)
Facility failed to maintain an orderly and sanitary environment with garbage bags, linens, and unpackaged incontinence briefs left in hallways.
Failure to report and thoroughly investigate an allegation of abuse involving a resident and a CNA, including failure to notify NJDOH timely.
Failed to complete significant change in status assessments timely for residents.
Failed to develop and implement comprehensive care plans reflecting residents' needs and physician orders.
Failed to ensure safe medication administration including supervision of medication ingestion and administration within prescribed time frames.
Failed to ensure residents are free of significant medication errors including administration of expired medications and improper timing.
Failed to label, store, and discard drugs and biologicals properly, including expired and discontinued medications.
Insufficient dietary support personnel resulting in delayed meal service and use of paper plates due to lack of clean dishware.
Menus did not consistently meet residents' nutritional needs and substitutions were made without prior dietitian approval.
Failed to serve food at safe and appetizing temperatures; food trays arrived late and some food items were cold.
Failed to maintain sanitary food service areas including uncovered food, expired items, unclean equipment, and pest presence.
Failed to provide meals/snacks at regular times consistent with residents' needs; meals were delayed and residents were not informed of menu changes.
Failed to maintain infection prevention and control program including proper use of PPE and hand hygiene.
Failed to maintain emergency lighting with battery backup above emergency generator transfer switch.
Failed to ensure vertical openings were enclosed with 1-hour fire rated construction; one stairwell door did not positive latch.
Failed to ensure hazardous areas were enclosed with self-closing fire rated doors; multiple storage rooms had doors that did not self-close.
Failed to provide sprinkler protection in certain areas; sprinkler head not properly installed and missing ceiling tiles.
Failed to maintain smoke barrier doors without gaps; one set of double doors had a one-inch gap between meeting edges.
Failed to maintain bathroom ventilation systems in 6 of 17 resident bathrooms; no operable windows or functioning exhaust fans.
Failed to install remote manual stop station for emergency generator as required.
Report Facts
Census: 212
Sample size: 38
Deficient CNA staffing days: 9
Deficient total staff days: 2
Deficient total staff days: 3
Fire rated doors tested: 11
Fire rated doors failed: 1
Resident bathrooms tested: 17
Resident bathrooms failed ventilation: 6
Emergency generator tests per year: 12
Emergency generator long test interval: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Flanagan | RN CIC- Regional Director of Clinical/Designee | Provided infection preventionist training |
| Director of Recreation | Designated LGBTQI and HIV+ program staff, trained in March 2022 | |
| Licensed Nursing Home Administrator | Responsible for staffing and program oversight | |
| Human Resources Director | Involved in LGBTQI and HIV+ program but not designated staff | |
| Director of Social Services | Designated LGBTQI and HIV+ program staff, awaiting training | |
| Licensed Practical Nurse/Unit Manager #3 | LPN/UM | Responsible for medication transcription and care plan updates |
| Director of Food Services | DOFS | Responsible for food service operations and menu substitutions |
| Assistant Director of Food Services | ADOFS | Assisted with food temperature testing |
| Maintenance Director | Responsible for facility maintenance and fire safety compliance |
Inspection Report
Complaint Investigation
Census: 225
Deficiencies: 2
Date: Feb 19, 2022
Visit Reason
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.
Complaint Details
Complaint numbers NJ152289, NJ152294, NJ152309, and NJ152310 triggered the investigation. The complaints were substantiated as evidenced by medication administration errors and staffing deficiencies.
Findings
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.
Deficiencies (2)
Failure to administer medications according to physician's orders and maintain accurate medication administration documentation for 6 of 7 residents.
Failure to ensure adequate nursing staff to provide care for residents on multiple shifts.
Report Facts
Resident census: 225
Sample size: 7
Medication omissions: 159
Medication errors: 159
Staffing shifts reviewed: 21
Staffing shifts reviewed: 16
Certified Nurse Aide (CNA) staffing: 17
Certified Nurse Aide (CNA) staffing: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to medication administration failures and staffing shortages. |
| LPN #2 | Licensed Practical Nurse | Named in findings related to medication administration failures and staffing shortages; did not respond to surveyor attempts to contact. |
| LPN #4 | Licensed Practical Nurse | Named in findings related to medication administration failures and staffing shortages. |
| Director of Nursing (DON) | Director of Nursing | Named in findings related to staffing issues and responses to medication administration failures. |
| Staffing Coordinator | Named in findings related to staffing shortages and education on medication administration. | |
| Administrator | Named in findings related to staffing and medication administration audits and education. | |
| Regional Director of Clinical / designee | Named in findings related to education of licensed nurses on medication administration. |
Inspection Report
Complaint Investigation
Census: 191
Deficiencies: 2
Date: Dec 14, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ149849 and NJ150192, focusing on infection control practices during the COVID-19 pandemic.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to provide personal protective equipment (PPE) and isolation precaution signage outside the door of a resident's room on isolation (Resident #1).
Staff failed to don PPE prior to entering a resident's room that was on isolation precautions (Resident #5).
Report Facts
Sample Size: 6
Deficiency Correction Completion Date: Feb 10, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Stated Resident #1 had been on isolation precautions and PPE was missing |
| Certified Nursing Assistant #2 | CNA | Observed entering Resident #5's room without PPE and admitted failure to gown up |
| Unit Manager #1 | UM | Interviewed while donning PPE to enter Resident #5's room and explained PPE requirements |
| Unit Manager #2 | UM | Found missing PPE cart and returned it to Resident #1's door |
| Director of Nursing | DON | Stated expectation that staff don PPE prior to entering isolation rooms and responsible for plan of correction oversight |
| Infection Preventionist | IP | Confirmed staff training on PPE use and isolation precautions |
Inspection Report
Complaint Investigation
Census: 203
Deficiencies: 3
Date: Oct 6, 2021
Visit Reason
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.
Complaint Details
Complaint numbers NJ148957 and NJ149122 triggered the investigation. The facility was found not in substantial compliance based on these complaints.
Findings
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.
Deficiencies (3)
Failure to develop and implement a comprehensive care plan for incontinence and discharge for 2 of 3 residents.
Failure to provide medically-related social services and assist a resident in obtaining needed services, including failure to follow discharge policy for 1 of 3 residents.
Failure to document physician's orders for medications and treatments for 1 of 3 residents.
Report Facts
Census: 203
Sample Size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in medication documentation deficiency and counseling. |
| MDS Coordinator | Interviewed regarding care plan development and confirmed missing incontinence care plan. | |
| Unit Manager/Licensed Practical Nurse | Unit Manager/LPN | Interviewed regarding care plan development and confirmed missing incontinence care plan. |
| Assistant Director of Nursing | ADON | Interviewed regarding discharge care planning responsibility. |
| Social Worker | SW | Named in failure to provide social services and discharge planning. |
| LPN #1 | Licensed Practical Nurse | Documented medication administration and discharge notes. |
| RN #1 | Registered Nurse | Explained medication administration and documentation process. |
Inspection Report
Complaint Investigation
Census: 185
Deficiencies: 1
Date: Aug 12, 2021
Visit Reason
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.
Complaint Details
Complaint Intake NJ145381. The complaint was substantiated as the facility failed to notify the responsible party of Resident #2's change in condition.
Findings
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.
Deficiencies (1)
Failure to notify a responsible party of a resident's change in condition.
Report Facts
Census: 185
Sample Size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed and acknowledged responsibility to notify physician, unit manager, and responsible party; admitted failure to notify responsible party for Resident #2. |
| Director of Nursing | Director of Nursing | Interviewed and confirmed Licensed Practical Nurse #4's responsibility and remorse for failure to notify responsible party. |
Inspection Report
Complaint Investigation
Census: 184
Deficiencies: 0
Date: Jun 5, 2021
Visit Reason
The inspection was conducted as a complaint survey related to complaints NJ144639, NJ143125, and NJ145865.
Complaint Details
Complaints NJ144639, NJ143125, and NJ145865 were investigated and the facility was found compliant.
Findings
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.
Report Facts
Sample Size: 10
Inspection Report
Annual Inspection
Census: 216
Deficiencies: 2
Date: Feb 24, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
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.
Deficiencies (2)
Failure to maintain a clean and sanitary environment and failure to adhere to facility wheelchair cleaning schedule, including spills not cleaned, dirt and debris in hallways and resident rooms, overflowing trash, and unclean wheelchairs.
Failure to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, including dented cans, unlabeled frozen foods, broken trash can lid in hand washing area, uncovered meat slicer, improperly stored sanitized pots and pans, and exposed Styrofoam cups.
Report Facts
Sample Size: 38
Wheelchairs cleaned per month: 240
Wheelchair cleaning schedule date: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Housekeeping | Interviewed regarding cleaning schedules and housekeeping audits | |
| Director of Nursing | Interviewed regarding wheelchair cleaning and facility practices | |
| Food Service Director | Interviewed regarding food safety and kitchen sanitation practices | |
| Registered Nurse/Unit Manager | Observed pantry conditions and disposal of exposed cups | |
| Licensed Practical Nurse | Observed in soiled utility room with sanitation issues | |
| Dietary Aide | Observed hand washing and issues with trash can lid |
Inspection Report
Life Safety
Deficiencies: 2
Date: Feb 24, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with Life Safety Code requirements, specifically focusing on fire safety and smoking regulations.
Findings
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.
Deficiencies (2)
Five of fifteen exhaust hood grease baffles were improperly positioned with gaps, allowing grease and fire to enter the exhaust hood system above the cooking apparatus.
The facility failed to comply with smoking regulations; the designated smoking area was littered with extinguished cigarette butts on concrete surfaces, water puddles, mulch beds, and snow, indicating unsafe smoking practices.
Report Facts
Exhaust hood grease baffles improperly positioned: 5
Designated smoking areas observed: 2
Approved cigarette butt receptacles: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged the improperly positioned grease baffles and unsafe smoking practices during observations and interviews | |
| Food Service Manager | Acknowledged the improperly positioned grease baffles during observations and interviews | |
| Food Services Director | Acknowledged the requirement for proper grease baffle positioning during interview | |
| Facility Administrator | Verbally informed of findings during Life Safety Code survey exit conference | |
| Recreation Director | Responsible for educating residents on proper disposal of cigarette butts and conducting audits of smoking area cleanliness |
Inspection Report
Complaint Investigation
Census: 207
Deficiencies: 0
Date: Jan 21, 2021
Visit Reason
The inspection was conducted based on complaints NJ131361 and NJ131059 to determine compliance with regulatory requirements.
Complaint Details
Complaint numbers NJ131361 and NJ131059 were investigated and found to be unsubstantiated as the facility was 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 the complaint survey.
Report Facts
Sample size: 12
Inspection Report
Routine
Census: 207
Deficiencies: 0
Date: Jan 21, 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 had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 7
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