Inspection Reports for Elizabeth Nursing And Rehab
1048 Grove Street, Elizabeth, NJ, 07202
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
79% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
86 residents
Based on a September 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census 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 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 about the notice |
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 10
Date: Sep 19, 2024
Visit Reason
A recertification survey was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facility, including complaint investigations.
Complaint Details
Complaint numbers NJ171411 and NJ175879 were investigated during the survey.
Findings
Deficiencies were cited related to reasonable accommodations for resident needs, medication labeling and storage, food procurement and sanitation, life safety code violations including exit signage, hazardous area enclosures, sprinkler system installation and maintenance, portable fire extinguishers, electrical equipment testing, and gas equipment storage.
Deficiencies (10)
Reasonable Accommodations Needs/Preferences - failure to provide safe medical equipment (wheelchair) for a resident.
Label/Store Drugs and Biologicals - failure to remove discontinued medications and improper storage and labeling of medications.
Food Procurement, Store/Prepare/Serve - Sanitary - failure to maintain proper kitchen sanitation, including black substance in ice machine.
Exit Signage - failure to provide exit signs showing direction of travel in all required locations.
Hazardous Areas - Enclosure - failure to ensure hazardous area doors had self-closing devices.
Sprinkler System - Installation - failure to provide sprinkler coverage in right exit stairwell landing areas.
Sprinkler System - Maintenance and Testing - missing escutcheon plates on sprinklers and missing ceiling tiles.
Portable Fire Extinguishers - fire extinguishers blocked by kitchen plate storage rack.
Electrical Equipment - Testing and Maintenance - failure to maintain inspection stickers and records for patient care related electrical equipment.
Gas Equipment - Cylinder and Container Storage - failure to separate empty oxygen cylinders from full cylinders.
Report Facts
Sample Size: 20
Residents observed: 18
Medication carts inspected: 4
Resident beds first floor: 54
Resident beds second floor: 47
Oxygen cylinders empty: 4
Inspection Report
Routine
Deficiencies: 3
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, medication management, medical equipment safety, and kitchen sanitation.
Findings
The facility was found deficient in providing safe medical equipment (missing wheelchair armrest cushion for one resident), proper medication management (failure to remove discontinued medication and improper storage/labeling of medications), and maintaining kitchen sanitation (presence of black substance in ice machine). These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failed to provide a safe medical equipment (wheelchair with no armrest pad) for one resident.
Failed to remove and dispose of discontinued medication and properly label, store, and dispose medications in medication carts.
Failed to maintain proper kitchen sanitation; black colored substance found inside ice machine.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: Few
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Acknowledged missing armrest cushion on Resident #23's wheelchair and stated it needed to be fixed | |
| Certified Nursing Assistant (CNA) | Acknowledged Resident #23 had no armrest cushion and that it should be on both armrests | |
| Licensed Practical Nurse (LPN#1) | Observed preparing medications and acknowledged discontinued Namenda 5 mg should have been removed | |
| Licensed Practical Nurse (LPN#2) | Acknowledged discontinued medication and improper storage of PPD vial and Basaglar insulin | |
| Licensed Practical Nurse (LPN#3) | Acknowledged expired Timolol eye drops should have been removed | |
| Chef | Observed black colored substance inside ice machine | |
| Maintenance Director (MD) | Reported ice machine cleaned monthly but unaware of black substance | |
| Executive Chef (EC) | Provided facility policy on cleaning kitchen equipment | |
| Licensed Nursing Home Administrator (LNHA) | Part of administrative team presented with survey concerns | |
| Assistant LNHA | Part of administrative team presented with survey concerns | |
| Regional LNHA | Part of administrative team presented with survey concerns | |
| Director of Nursing (DON) | Provided facility policies and part of administrative team presented with survey concerns |
Inspection Report
Abbreviated Survey
Census: 82
Deficiencies: 0
Date: Aug 23, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and in substantial compliance with 42 CFR 483 subpart B for infection control.
Report Facts
Sample Size: 6
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 23, 2023
Visit Reason
The inspection was conducted as an annual survey of Elizabeth Nursing and Rehab to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Census: 78
Capacity: 102
Deficiencies: 11
Date: May 15, 2023
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 comprehensive nutritional assessments, food safety, staffing ratios, life safety code violations including exit door signage, illumination of means of egress, fire alarm system testing, hazardous area door compliance, electrical receptacle safety, and generator testing.
Deficiencies (11)
Facility failed to provide comprehensive nutritional assessments within 14 days for newly admitted/re-admitted residents.
Facility failed to store, label, and date potentially hazardous foods properly to prevent food-borne illness.
Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Exit doors locked with delayed egress devices lacked required instructional signage.
Emergency illumination along means of egress was not provided or did not operate automatically in some occupied areas.
Exit signs lacked continuous illumination indicator in some locations where direction of travel was not apparent.
Fire-rated doors to hazardous areas were not self-closing, labeled, or properly separated by smoke resisting partitions.
Fire alarm system smoke detector sensitivity testing was not documented as completed.
Electrical outlet near water source was not equipped with required Ground-Fault Circuit Interrupter (GFCI) protection.
Facility failed to functionally test non-hospital grade electrical receptacles in resident rooms annually.
Generator transfer time to emergency power was not certified to be within 10 seconds as required.
Report Facts
Deficiencies cited: 11
Census: 78
Total licensed capacity: 102
Staffing deficiencies: 6
Staffing deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to multiple findings including fire safety, electrical, and generator testing. | |
| Administrator | Named in relation to multiple findings and exit conferences. | |
| Registered Dietitian | RD | Named in relation to nutritional assessment deficiencies. |
| Director of Nursing | DON | Named in relation to staffing and nutritional assessment findings. |
| Food Service Director | FSD | Named in relation to food safety deficiencies. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to nutritional assessments of newly admitted and re-admitted residents, as well as food storage and safety practices in the facility.
Findings
The facility failed to complete comprehensive nutritional assessments within the required 14-day period for 4 of 9 newly admitted/re-admitted residents due to lack of a covering Registered Dietitian during a vacation period. Additionally, the facility failed to properly store, label, and date potentially hazardous foods, including an opened container of Ricotta cheese with mold and undated frozen food items.
Deficiencies (2)
Failure to provide a comprehensive nutritional assessment within 14 days for newly admitted and re-admitted residents.
Failure to store, label, and date potentially hazardous foods to prevent food-borne illness.
Report Facts
Residents affected: 4
Residents reviewed: 9
Days late: 14
Days late: 8
Days late: 9
Days late: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian (RD) | Interviewed regarding delays in nutritional assessments and vacation period | |
| Food Service Director (FSD) | Interviewed regarding food storage and labeling deficiencies | |
| Chef Supervisor (CS) | Observed during kitchen tour and food storage inspection | |
| Licensed Nursing Home Administrator (LNHA) | Met with surveyor to discuss concerns | |
| Director of Nursing (DON) | Met with surveyor to discuss concerns | |
| Assistant Director of Nursing (ADON) | Met with surveyor to discuss concerns | |
| Assistant Licensed Nursing Home Administrator (ALNHA) | Met with surveyor to discuss concerns |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 2
Date: Jun 11, 2021
Visit Reason
A Federal Comparative survey was conducted from 06/07/2021 to 06/11/2021 to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not to be in substantial compliance due to failure to investigate an unexplained discoloration on resident #49 and failure to maintain resident #51's clinical condition within an acceptable range, including inadequate monitoring and documentation of lab values.
Deficiencies (2)
Failure to investigate and document an unexplained discoloration on resident #49.
Failure to maintain resident #51's clinical condition within an acceptable range, including inadequate monitoring and documentation of lab values.
Report Facts
Census: 57
Sample Size: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Interviewed regarding the unexplained discoloration on resident #49 and lack of documentation. | |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed and acknowledged failure to investigate and document the incident involving resident #49; initiated staff training and investigation. |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | Interviewed about knowledge of the discoloration on resident #49. |
Inspection Report
Routine
Census: 58
Deficiencies: 4
Date: Apr 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 reporting of alleged violations, drug regimen review, psychotropic drug use, and life safety code violations including inadequate bedroom square footage. Corrective actions and plans of correction were submitted and accepted.
Deficiencies (4)
Failure to report an allegation of abuse to the New Jersey Department of Health and failure to develop a policy on Abuse Prevention, Identification and Investigation for timely reporting.
Failure to ensure a medication recommendation was acted upon in a timely manner for 1 of 6 residents reviewed for medication management.
Failure to adequately monitor and document psychotropic medications and PRN use for 2 of 5 residents reviewed.
Failure to comply with minimum square footage requirements for 4 of 4 resident rooms measured during the survey.
Report Facts
Census: 58
Sample Size: 25
Deficiencies cited: 4
Resident rooms measured: 4
Beds per room: 1
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 29, 2021
Visit Reason
The inspection was conducted to investigate allegations of resident-to-resident abuse and to review medication management and psychotropic medication monitoring practices at the facility.
Complaint Details
The complaint investigation focused on an incident of resident-to-resident verbal abuse that occurred on 3/2/21 between Resident #2 and Resident #37. The facility failed to report this allegation to the NJDOH in a timely manner and did not update its abuse prevention policy to reflect required reporting timelines. The Director of Nursing initially did not consider the verbal threats as abuse due to the residents' relationship but later acknowledged the need to report such incidents.
Findings
The facility failed to timely report an allegation of resident-to-resident verbal abuse to the New Jersey Department of Health, failed to act on Consultant Pharmacist recommendations in a timely manner for medication management, and failed to adequately monitor target behaviors for psychotropic medication use for two residents. Additionally, the facility did not comply with minimum square footage requirements for certain resident rooms.
Deficiencies (4)
Failure to timely report an allegation of resident-to-resident verbal abuse to the NJDOH and failure to update the facility's Abuse Prevention, Identification and Investigation policy accordingly.
Failure to ensure a recommendation made by the Consultant Pharmacist was acted upon in a timely manner regarding medication refusals for Resident #6.
Failure to adequately monitor target behaviors for the use of psychotropic medications for Residents #2 and #17, including missing Behavior/Intervention Monthly Flow Records (BIMFR) for April 2021.
Failure to provide rooms that meet minimum square footage requirements for private and semi-private resident bedrooms for 4 resident rooms.
Report Facts
Residents affected: 1
Residents affected: 6
Residents affected: 2
Resident rooms: 4
Square footage: 145
Square footage: 85.5
Medication refusal attempts: 3
BIMS score: 3
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | In charge of abuse investigations and reporting to NJDOH; acknowledged failure to report verbal abuse and need to update policy |
| Licensed Nursing Home Administrator | LNHA | Acknowledged no physical injury to Resident #37 and initial decision not to report verbal abuse incident |
| Assistant Licensed Nursing Home Administrator | Assistant LNHA | Acknowledged verbal abuse should have been reported despite no physical injury |
| Licensed Practical Nurse | LPN | Provided information about Resident #6's medication refusals and care |
| Consultant Pharmacist | Consultant Pharmacist (CP) | Made recommendations regarding medication refusals; stated documentation was lacking |
| Nursing Supervisor | Evening Nurse Supervisor | Acknowledged missed CP recommendations and proper procedures after surveyor inquiry |
| Nursing Supervisor | Nursing Supervisor (NS) | Described process for monitoring psychotropic medications and confirmed missing behavior monitoring forms |
| Registered Nurse | RN | Confirmed missing Behavior/Intervention Monthly Flow Records for Residents #2 and #17 |
| Assistant Director of Nursing | ADON | Discussed missing behavior monitoring forms and transition to electronic health records |
| Maintenance Director | Maintenance Director | Confirmed room size measurements during building tour |
| Facility Administrator | Administrator | Acknowledged room size deficiencies and COVID-19 related room use changes |
Inspection Report
Life Safety
Deficiencies: 1
Date: Apr 26, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 4/26/21 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code for existing health care occupancies.
Findings
The facility was found to be in noncompliance due to failure to maintain the automatic sprinkler system in safe condition; specifically, 6 of 7 sprinkler heads in the kitchen were tarnished and covered with grease-laden dust, which could delay their operation.
Deficiencies (1)
Automatic sprinkler heads in the kitchen were tarnished with greenish discoloration and covered with grease-laden dust, potentially preventing or delaying their operation.
Report Facts
Number of affected sprinkler heads: 6
Completion date for corrective actions: May 18, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Facility Maintenance Director was present during observation, unaware of the sprinkler head condition, and was reeducated on checking sprinkler heads |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Jan 8, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ00134874, NJ00133239, NJ00135883, and NJ00134686.
Complaint Details
Complaint numbers NJ00134874, NJ00133239, NJ00135883, and NJ00134686 were investigated and 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 survey.
Report Facts
Sample Size: 8
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Jan 8, 2021
Visit Reason
A COVID-19 Focused Infection Control and Complaint Survey was conducted to assess compliance with Medicare regulations and CDC recommended practices for COVID-19 preparation.
Complaint Details
The survey was complaint-related and focused on COVID-19 infection control; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare regulations at 42 CFR Part 483, Subpart B, and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
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