Inspection Reports for
Echelon Care & Rehab

Complaint NJ #: 177921 regarding unsafe and unsanitary resident environment including damaged flooring and broken chair rails.

The facility was found deficient in maintaining a safe and homelike environment, including damaged flooring, broken chair rails, and unrepaired wallboard in multiple nursing units. Additional deficiencies included failure to complete a Significant Change in Status Assessment for a hospice resident, improper pressure ulcer care related to low air loss mattress settings and heel elevation, unsafe Packaged Terminal Air Conditioner (PTAC) units, and unsecured handrails with splinters or missing sections.

Complaint #NJ00170177 was substantiated with findings that the facility was not in substantial compliance with regulations related to resident records and documentation.

The facility failed to document notification to the resident's Responsible Representative regarding medication changes for one resident and failed to consistently document Activities of Daily Living (ADL) care for two residents according to facility policy and protocol.

The investigation was complaint-driven, focusing on documentation deficiencies related to medication notification and ADL care documentation. The report notes that the deficiencies affected a few residents and were substantiated by medical record reviews and interviews.

The facility failed to document notification to the resident's Responsible Representative about a medication increase for one resident and failed to consistently document ADL care provided or refused for two residents, contrary to facility policy and protocol.

Complaint numbers NJ00158413, NJ00159043, NJ00159091, NJ00157069, NJ00156915, NJ00155925, NJ00156539, NJ00159631 triggered the complaint investigation and recertification survey.

Deficiencies were cited related to failure to notify resident representatives of changes in condition, failure to maintain a safe, clean, comfortable environment, inaccurate assessments, medication administration errors, failure to follow pain management protocols, pharmacy service deficiencies, improper medication storage and labeling, food safety violations, infection control lapses, failure to meet staffing ratios, and failure to provide required resident activities.

Complaint NJ #:159091 involved failure to notify a resident's representative of a positive COVID-19 test. Complaints NJ00156539 and NJ00156915 involved food temperature and food safety violations.

The facility failed to notify the resident's representative of a positive COVID-19 test and refusal of dental care for one resident. The kitchen failed to serve hot foods at proper temperatures and had multiple sanitation and food safety violations including improper hair coverings, uncovered or improperly labeled food, inadequate sanitizer levels, and insufficient emergency food supplies.

Complaint NJ #:159091 and NJ00156539 and NJ00156915. Complaints included failure to notify family of resident condition changes, inadequate laundry service, environmental maintenance issues, inaccurate resident assessments, medication administration errors, pain management concerns, medication storage and labeling issues, food safety and temperature violations, and infection control lapses.

The facility was found deficient in multiple areas including failure to notify a resident's representative of a positive COVID-19 test, failure to maintain timely laundry services and repair environmental damages, inaccurate Minimum Data Set (MDS) assessments, improper medication administration and documentation, inadequate pain management, improper medication storage and labeling, failure to maintain safe food temperatures and proper food handling, and lapses in infection control practices during medication administration.

The facility was found noncompliant with several Life Safety Code requirements including illumination of means of egress, sprinkler system installation, portable fire extinguisher maintenance, corridor door smoke resistance, smoke barrier door functionality, HVAC ventilation in bathrooms, laundry chute door latching, electrical outlet GFCI protection, and emergency generator testing and documentation.

Complaint #NJ165964 was substantiated as the facility failed to report and investigate an alleged abuse incident involving Resident #2. The incident involved inappropriate touching and loud, sexually inappropriate comments by Resident #3. The Director of Nursing and Administrator acknowledged the failure to report to NJDOH. The facility policy was reviewed and found not properly implemented.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to report an allegation of abuse involving Resident #2 to the New Jersey Department of Health and to properly investigate the incident. The facility also failed to implement its Incident and Accident Report and Investigation policy. The deficient practice involved 3 of 4 residents reviewed.

Complaint #NJ165964 involved an allegation that Resident #2 exposed himself/herself to Residents #3 and #4. The complaint was substantiated by observation, interviews, and record review. The facility failed to report the incident to the NJDOH and failed to conduct a thorough investigation as required by policy.

The facility failed to report the alleged exposure incident to the NJDOH and did not conduct a thorough investigation or properly document the incident as required by their policy. The Director of Nursing acknowledged the failure to report, and the Administrator disagreed on the need to report. The Social Worker conducted some investigation but no completed investigation report was provided at the time of the survey.

Complaint numbers NJ 153072, 154593, 155483, 155484. The facility was found not in substantial compliance based on this complaint visit.

The facility failed to maintain a clean, sanitary, and homelike environment in good repair, particularly on the 4th and 5th floors, elevators, and a Day Room. Observations included dust buildup, loose chair rails with exposed nails, jagged door edges, and dirty elevator walls and floors. Residents reported dissatisfaction with cleanliness despite housekeeping efforts.

Deficiencies were cited related to advance directives documentation, medication administration, food temperature and safety, infection control practices, staffing ratios, and life safety code violations including emergency lighting, fire alarm system maintenance, sprinkler system issues, corridor door latching, smoke barrier doors, HVAC ventilation, electrical equipment safety, and oxygen cylinder storage.

The facility was found deficient in maintaining accurate advance directives, administering medications as ordered, serving food at appropriate temperatures, proper food handling and storage, infection control practices including PPE use, and proper cleaning and storage of respiratory equipment.

The facility was found to be in noncompliance with several life safety code requirements including emergency illumination, emergency lighting, fire alarm system maintenance, sprinkler system maintenance, corridor door latching, smoke barrier door functionality, HVAC ventilation in resident bathrooms, electrical equipment safety, and oxygen cylinder storage.

The facility failed to ensure staff properly donned and doffed personal protective equipment (PPE) on units housing persons under investigation for COVID-19 and failed to prevent cross contamination of a common area identified as non-contaminated (clean). Multiple staff were observed wearing contaminated gowns in hallways and not following proper PPE protocols, including improper handling of medication carts and resident transfers through clean areas.