Inspection Reports for
Deptford Center For Rehabilitation And Healthcare

The complaint investigation found that the medication administration documentation for Resident #7 was not completed at the time of administration but was delayed by several days. The deficiency was substantiated with evidence from medication administration records and interviews with the Director of Nursing and Licensed Practical Nurse.

The facility failed to ensure timely documentation of medication administration for Resident #7, where the levothyroxine dose given on 9/19/25 was signed as administered on 10/9/25, contrary to facility policy requiring immediate documentation after administration.

The facility was found deficient in multiple areas including failure to notify residents about Personal Needs Account balances approaching Medicaid/SSI limits and failure to return funds within 30 days of discharge or death; improper setting and operation of a low air loss mattress for pressure ulcer prevention; inaccurate controlled medication inventory and documentation; failure to timely respond to Consultant Pharmacist recommendations; and unsanitary kitchen equipment maintenance.

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 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 found that Resident 9 had nausea and vomiting and was ordered a gastric emptying test which was not completed due to vomiting prior to the test. The test was not rescheduled due to a communication breakdown between nursing and medical records staff. The Director of Nursing and Nurse Practitioner were not notified that the test was not completed or rescheduled.

The facility failed to ensure that Resident 9 had a gastric emptying scan completed as ordered. There was a breakdown in communication between nursing and medical records staff, resulting in the test not being rescheduled after the resident vomited prior to the procedure and the appointment was not completed.

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.

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 investigation involved multiple incidents of alleged resident-to-resident abuse by Resident 5 against Residents 6, 9, 25, and 30. Investigations concluded the abuse was not substantiated due to the unpredictable and isolated nature of the events related to psychiatric diagnoses. Additionally, the facility failed to submit investigation results to the State Survey Agency within required timeframes for 10 residents, potentially delaying corrective actions.

The facility failed to ensure four residents were free from resident-to-resident abuse perpetrated by another resident, and failed to timely report the results of abuse/neglect investigations to the State Survey Agency within five business days for 10 out of 13 residents reviewed. Investigations found abuse incidents were isolated and not substantiated due to residents' psychiatric diagnoses and behaviors. Interventions were implemented to prevent further incidents.

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 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 #NJ169732 and Complaint #NJ170765 triggered the investigation. The deficiencies were substantiated based on observations, interviews, and document reviews.

The facility was found deficient in providing a homelike dining experience as meals were served on trays without placemats or tablecloths, and food was left on trays rather than placed on tables. Additionally, the facility environment was not properly maintained, with issues such as dust and exposed suction tubing on the crash cart, unclean wheelchairs, stained privacy curtains not being changed, and food debris left on chairs in hallways.

The facility was found deficient in multiple areas including failure to maintain resident dignity and appropriate clothing, failure to protect resident confidentiality, inadequate dining environment and food service, failure to educate residents on grievance process, inaccurate PASARR screening, incomplete care plans, failure to provide care according to professional standards, inadequate range of motion treatments, insufficient staffing levels, incomplete narcotic accountability, improper medication storage and labeling, unsafe food handling and storage, failure to provide dietary supplements as ordered, and lapses in infection prevention and control practices.

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

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 investigation was based on complaints NJ00165456, NJ00168282, NJ00168313, NJ00164862, and NJ00168836, which included allegations of failure to develop care plans, provide wound care, and document care properly.

The facility failed to develop baseline and comprehensive care plans addressing pain and life-threatening events for residents, did not provide timely wound care treatment for a pressure ulcer, and failed to consistently document Activities of Daily Living (ADL) care and monitoring for multiple residents. These deficiencies were supported by medical record reviews, interviews, and policy reviews.

Complaint numbers NJ00159849 and NJ00163909 were investigated. The complaint was substantiated as the facility failed to ensure sufficient staffing to meet resident needs.

The facility failed to ensure sufficient nursing staff to meet the needs of 138 residents, resulting in long wait times for care and assistance. Staff and residents reported concerns about staffing shortages, especially on weekends and nights, and the facility acknowledged ongoing recruitment challenges and use of agency staff as a last resort.

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 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.

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.

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.

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 facility was found deficient in multiple areas including failure to maintain a sanitary environment, failure to report and investigate abuse allegations properly, failure to complete significant change assessments, failure to update care plans, failure to follow physician orders for orthotics and side rail pads, failure to complete neurological checks after falls, medication administration errors including expired insulin and improper timing, improper storage and labeling of medications, insufficient kitchen staffing leading to delayed and incomplete meals, failure to maintain food safety and sanitation standards, and failure to follow infection control protocols including PPE use and hand hygiene.

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

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.

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 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.

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

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

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.

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 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.