Inspection Reports for Hammonton Center For Rehabilitation And Healthcare
43 N White Horse Pike, NJ, 08037
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
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 explains 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 | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Census: 190
Deficiencies: 0
Feb 27, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint numbers NJ179042, NJ181470, NJ182492, NJ183005, and NJ183618.
Findings
The facility was found to be in compliance with the standards in the New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long-Term Care Facilities.
Complaint Details
The visit was complaint-related with multiple complaint numbers cited. The facility was found compliant with no deficiencies noted.
Report Facts
Sample size: 10
Inspection Report
Complaint Investigation
Census: 182
Capacity: 240
Deficiencies: 3
Nov 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints (NJ00176261, NJ00176273, NJ00177933, NJ00178817, NJ00179250, NJ00179283) to determine compliance with federal and state regulations.
Findings
The facility was found not in substantial compliance with requirements, with deficiencies related to failure to develop comprehensive person-centered care plans, inadequate staffing ratios, and failure to provide a full-time administrator. Deficient practices were identified for one resident and staffing shortages were documented for multiple shifts.
Complaint Details
The complaint investigation was based on multiple complaint numbers. The facility was found not in substantial compliance with federal and state regulations. Specific deficiencies included failure to develop comprehensive care plans for a resident and failure to maintain required staffing ratios. The facility also failed to provide a full-time administrator as required. The complaint was substantiated based on observations, interviews, and document reviews.
Severity Breakdown
Level D: 1
Level F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan for a resident, including measurable objectives and timeframes. | Level D |
| Failure to ensure staffing ratios met state-mandated minimums for Certified Nurse Aides (CNAs) on multiple day shifts. | Level F |
| Failure to provide a full-time administrator as required for facilities with 100 or more beds. | Level F |
Report Facts
Census: 182
Total licensed beds: 240
Sample size: 9
CNA staffing deficiency counts: 7
CNA staffing counts: 19
CNA staffing counts: 20
CNA staffing counts: 22
CNA staffing counts: 20
CNA staffing counts: 18
CNA staffing counts: 20
CNA staffing counts: 18
CNA staffing counts: 20
CNA staffing counts: 21
CNA staffing counts: 20
CNA staffing counts: 22
Inspection Report
Complaint Investigation
Census: 177
Deficiencies: 1
Sep 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaint NJ:00164772 to determine compliance with federal and state regulations regarding staffing ratios.
Findings
The facility was found not in compliance with New Jersey Administrative Code staffing requirements, failing to meet minimum staff-to-resident ratios on multiple shifts. The facility submitted a plan of correction and added agency staffing to meet required ratios.
Complaint Details
Complaint #: NJ:00164772. The facility was found to be deficient in staffing ratios during the complaint investigation but was in substantial compliance overall.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 3 of 14-day shifts. |
Report Facts
Census: 177
Deficient shifts: 3
Staffing ratios: 23
Staffing ratios: 13
Inspection Report
Routine
Census: 172
Capacity: 179
Deficiencies: 17
Jul 31, 2024
Visit Reason
Routine standard survey conducted to assess compliance with Medicare and Medicaid requirements for long term care facilities, including emergency preparedness and various regulatory standards.
Findings
The facility was found not in substantial compliance with several regulatory requirements including Medicaid/Medicare coverage notices, transfer/discharge notifications, comprehensive care plans, medication administration, life safety code violations, and food safety. Deficiencies were cited across multiple areas with plans of correction required.
Severity Breakdown
Level D: 17
Deficiencies (17)
| Description | Severity |
|---|---|
| Facility failed to issue required beneficiary notices to Medicaid-eligible residents. | Level D |
| Facility failed to notify representatives of resident transfers or discharges in a timely manner. | Level D |
| Facility failed to complete significant change assessments using the Resident Assessment Instrument (RAI) process. | Level D |
| Facility failed to develop and implement comprehensive person-centered care plans. | Level D |
| Facility failed to implement infection control measures for nebulizer equipment. | Level D |
| Facility failed to maintain kitchen sanitation and food safety standards. | Level D |
| Facility failed to maintain adequate staffing levels as mandated by state regulations. | Level D |
| Facility failed to maintain accurate medication administration records and follow physician orders. | Level D |
| Facility failed to maintain fire safety code compliance including exit access, fire alarm functions, and smoke barrier doors. | Level D |
| Facility failed to maintain adequate ventilation in resident bathrooms. | Level D |
| Facility failed to maintain accurate pharmacy records and controlled substance documentation. | Level D |
| Facility failed to maintain smoking regulations and assessments. | Level D |
| Facility failed to maintain adequate supervision and safety measures to prevent accidents. | Level D |
| Facility failed to maintain adequate tube feeding and enteral nutrition care. | Level D |
| Facility failed to maintain adequate respiratory care and tracheostomy suctioning. | Level D |
| Facility failed to maintain accurate transfer/discharge notifications and reporting. | Level D |
| Facility failed to maintain adequate fire safety exit signage and door locking arrangements. | Level D |
Report Facts
Census: 172
Total Capacity: 179
Sample Size: 36
Deficiency Count: 17
Inspection Report
Complaint Investigation
Census: 157
Deficiencies: 4
Feb 21, 2024
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health covering multiple complaint numbers between 02/19/24 and 02/21/24.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities based on the complaint visit. Deficiencies included failure to ensure timely medication administration, improper food safety practices, inadequate infection prevention and control, and failure to meet minimum staffing ratios.
Complaint Details
The complaint survey was triggered by multiple complaint numbers including NJ00157908, NJ00158950, NJ00160690, NJ00163716, NJ00163849, NJ00164954, NJ00158151, NJ00165000, NJ00165571, NJ00160246, NJ00163037, NJ00163593, NJ00163664, NJ00163862, and NJ00166486.
Severity Breakdown
SS=E: 1
SS=F: 1
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure timely administration of medication for one resident, with multiple late doses documented. | SS=E |
| Failure to ensure clean plates and pans were air dried prior to storage and not stacked wet, risking foodborne illness. | SS=F |
| Failure to maintain effective infection control practices including improper sanitization of equipment and staff wearing false nails during medication administration. | SS=D |
| Failure to maintain required minimum staff-to-resident ratios as mandated by the state of New Jersey for 8 of 14 day shifts. | — |
Report Facts
Survey Census: 157
Sample Size: 15
Late medication administrations: 4
Staffing deficiency days: 8
Required CNAs for day shift: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Named in infection control deficiency for improper sanitization and wearing false nails during medication administration. |
| LPN 8 | Licensed Practical Nurse | Interviewed regarding late medication administration for Resident #11. |
| LPN 9 | Licensed Practical Nurse | Interviewed regarding documentation of medication administration. |
| LPN 10 | Licensed Practical Nurse | Interviewed regarding medication administration timing and documentation. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration expectations and infection control policies. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication administration expectations. |
| Corporate Nurse | Corporate Nurse | Interviewed regarding medication administration expectations and infection control. |
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 0
Dec 14, 2023
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ164797, NJ165814, and NJ166196.
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.
Complaint Details
Complaint numbers NJ164797, NJ165814, and NJ166196 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 146
Deficiencies: 1
Nov 14, 2023
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ158236, NJ158655, and NJ165509 to determine compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 standards for licensure of Long Term Care Facilities due to failure to meet minimum staffing requirements across multiple shifts during the review period. The facility submitted a Plan of Correction addressing staffing deficiencies and implemented measures to improve staffing levels.
Complaint Details
Complaint numbers NJ158236, NJ158655, and NJ165509 were investigated. The facility was found deficient in staffing ratios during the complaint investigation period from 09/18/2022 to 10/01/2022 and again prior to survey from 10/29/2023 to 11/11/2023. No residents were noted to have been directly affected by the deficient practice, but all residents had the potential to be affected.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 14 of 14-day shifts, deficient in total staff for residents on 5 of 14 evening shifts, deficient in CNAs to total staff on 1 of 14 evening shifts, and deficient in total staff for residents on 12 of 14 overnight shifts. |
Report Facts
Census: 146
Sample Size: 8
Staffing Deficiencies: 14
Staffing Deficiencies: 5
Staffing Deficiencies: 1
Staffing Deficiencies: 12
Staffing Deficiencies: 5
Inspection Report
Complaint Investigation
Census: 185
Deficiencies: 2
Jun 13, 2023
Visit Reason
Complaint investigation triggered by complaint NJ 164849 regarding failure to administer physician-ordered medications timely and in accordance with professional standards.
Findings
The facility failed to administer medications within the prescribed timeframes for multiple residents on several units, resulting in an Immediate Jeopardy situation. Medication errors were documented, medical directors and physicians were notified, and residents were evaluated with no lasting negative effects noted. The facility also failed to maintain required minimum direct care staff to resident ratios as mandated by New Jersey regulations.
Complaint Details
Complaint NJ 164849 substantiated. Immediate Jeopardy was identified due to medication administration failures and staffing deficiencies.
Severity Breakdown
SS=L: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to administer physician-ordered medications timely for 18 of 45 residents, including insulin and other medications, across multiple units and floors. | SS=L |
| Failure to maintain required minimum direct care staff to resident ratios as mandated by New Jersey regulations. | — |
Report Facts
Residents at risk for medication errors: 18
Census: 185
Staffing deficiency days: 7
Required CNAs: 22
Actual CNAs: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #3 | Refused assignment to 1st floor B unit on 6/10/2023, contributing to medication administration failures. | |
| Director of Nursing (DON) | Notified of Immediate Jeopardy and staffing issues; confirmed use of liberal medication pass policy. | |
| Unit Manager LPN | Confirmed incomplete medication passes on 1st floor units during inspection. |
Inspection Report
Routine
Census: 186
Deficiencies: 8
Jun 5, 2023
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 not in compliance with several federal and state regulations including resident rights, dignity and privacy, reasonable accommodations, accuracy of assessments, care planning, treatment and services, sufficient nursing staff, pharmacy services, nutrition and hydration, and life safety code requirements. Multiple deficiencies were cited with corrective actions required.
Deficiencies (8)
| Description |
|---|
| Resident rights related to dignity and privacy were not fully respected, including issues with resident assessments and staff observations. |
| Reasonable accommodations for residents to move about the facility and access their rooms were not adequately provided. |
| Accuracy of assessments was deficient, with incomplete or inaccurate Minimum Data Set (MDS) documentation. |
| Care planning and provision of services did not meet professional standards, including failure to implement physician orders and inadequate treatment for dependent residents. |
| Insufficient nursing staff to meet the needs of residents, with documented staffing shortages and failure to meet minimum staffing ratios. |
| Pharmacy services failed to ensure accurate medication administration and reconciliation. |
| Nutrition and hydration services were deficient, including failure to provide adequate fluid intake and proper diet modifications. |
| Life safety code violations including issues with egress doors, fire alarm systems, sprinkler systems, fire extinguishers, and smoke barriers. |
Report Facts
Census: 186
Sample Size: 35
Sample Size: 3
Staffing Ratios: 1
Staffing Ratios: 1
Staffing Ratios: 1
Inspection Report
Life Safety
Deficiencies: 11
May 18, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 05/18/2023 and 05/19/2023 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for Hammonton Center For Rehabilitation and Healthcare.
Findings
The facility was found noncompliant with multiple Life Safety Code requirements including egress door accessibility, vertical opening enclosures, hazardous area door self-closure, fire alarm system installation, sprinkler system installation, portable fire extinguisher maintenance, corridor openings, smoke barrier integrity, smoke barrier door gaps, HVAC ventilation, and emergency generator remote stop station installation.
Severity Breakdown
SS=E: 9
SS=D: 1
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to provide 1 of 11 designated exit discharge doors readily accessible and free of obstructions; thumb turn locks on main entrance doors could restrict emergency use. | SS=E |
| One of 14 exit access stairwell doors failed to positively latch to maintain 1-1/2 hour fire rated construction. | SS=D |
| Fire-rated doors to hazardous areas were not self-closing and separated by smoke resisting partitions as required. | SS=E |
| Failed to provide fire alarm notification by audible and visible signals for 1 of 3 outside enclosed courtyards. | SS=E |
| Damaged or missing ceiling tiles in multiple locations compromised sprinkler system coverage. | SS=E |
| Failed to perform hydrostatic testing for 16 of 28 portable fire extinguishers as required. | SS=E |
| Transfer grills installed in corridor walls on resident sleeping units without smoke/fire dampers. | SS=E |
| Failed to maintain integrity of smoke barrier partitions due to penetrations with electrical cables and pipes. | SS=E |
| Smoke barrier doors had gaps exceeding 3/4 inch at bottom edges, allowing transfer of smoke and fire. | SS=F |
| Five of 14 resident bathroom exhaust systems failed to function properly, compromising ventilation. | SS=E |
| Emergency generator lacked a remote manual stop station as required by NFPA 110. | SS=E |
Report Facts
Designated exit discharge doors inspected: 11
Exit access stairwell doors tested: 14
Outside enclosed courtyards inspected: 3
Portable fire extinguishers inspected: 28
Resident sleeping rooms: 120
Smoke barrier walls: 11
Double corridor smoke doors tested: 10
Resident bathroom exhaust systems tested: 14
Inspection Report
Complaint Investigation
Census: 193
Deficiencies: 10
Oct 14, 2022
Visit Reason
Complaint investigation triggered by allegations of abuse and failure to follow abuse policies involving Resident #2 and staff member LPN #1.
Findings
The facility was found not in substantial compliance with abuse policies after a physical altercation between Resident #2 and LPN #1 resulted in injury to the resident. Additional deficiencies included failure to keep call bells within reach for some residents, inadequate reporting of abuse allegations, insufficient staffing levels, failure to maintain a safe environment free of pests, improper infection control practices related to ice scoop storage, and failure to provide timely incontinence care.
Complaint Details
Complaint numbers NJ158446 and NJ158513 involved allegations of abuse and failure to follow abuse policies, resulting in an Immediate Jeopardy situation that was identified and reported to the facility's Director of Nursing and Assistant Director of Nursing on 10/13/2022. The complaint investigation included review of medical records, interviews with staff and residents, and observation of care practices.
Severity Breakdown
Level G: 2
Level J: 1
Level E: 1
Level D: 5
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to follow and implement Abuse Policy and Procedure for Resident #2 after a physical altercation with staff resulting in injury. | Level G |
| Failure to keep call bell system within reach for 3 residents dependent on staff for transfers. | Level E |
| Failure to protect residents from abuse and neglect, including failure to suspend accused staff immediately and failure to report allegations timely. | Level G |
| Failure to develop and implement abuse and neglect policies and procedures including staff training. | Level J |
| Failure to report alleged violations involving abuse and injuries of unknown origin timely and completely to appropriate authorities. | Level D |
| Failure to maintain a safe environment free from accident hazards; resident was allowed to carry oxygen inside the building contrary to policy. | Level D |
| Failure to provide timely and adequate incontinence care to Resident #4, including failure to change soiled linens and provide perineal care. | Level D |
| Failure to properly store ice scoop used for resident drinking water, risking contamination. | Level D |
| Failure to maintain effective pest control program; flies and gnats observed in resident rooms and bathrooms. | Level D |
| Failure to maintain minimum required staffing levels for Certified Nursing Assistants (CNAs) on day, evening, and night shifts. | — |
Report Facts
CNA staffing: 9
CNA staffing: 8
CNA staffing: 13
CNA staffing: 15
CNA staffing: 15
CNA staffing: 15
CNA staffing: 14
CNA staffing: 11
CNA staffing: 14
CNA staffing: 14
CNA staffing: 13
CNA staffing: 16
CNA staffing: 14
CNA staffing: 16
CNA staffing: 17
CNA staffing: 7
CNA staffing: 9
CNA staffing: 12
CNA staffing: 13
CNA staffing: 12
CNA staffing: 11
CNA staffing: 11
CNA staffing: 11
CNA staffing: 13
CNA staffing: 12
CNA staffing: 13
CNA staffing: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in abuse allegation and physical altercation with Resident #2. |
| Nursing Supervisor/LPN #2 | Nursing Supervisor / Licensed Practical Nurse | Reported abuse incident and conducted visual assessment of Resident #2. |
| DON | Director of Nursing | Informed of abuse incident and responsible for oversight. |
| ADON | Assistant Director of Nursing | Informed of abuse incident and provided statements about Resident #2's behaviors. |
| CNA #1 | Certified Nursing Assistant | Witnessed altercation and called 911. |
| CNA #2 | Certified Nursing Assistant | Assigned to Resident #7 and reported call bell issues. |
| Unit Manager | Unit Manager | Provided statements about call bell policy and ice scoop storage. |
| Maintenance Director | Maintenance Director | Reported on ice scoop holder status. |
| Housekeeping Director | Housekeeping Director | Reported on pest control and exterminator visits. |
Inspection Report
Complaint Investigation
Census: 195
Deficiencies: 0
Jul 15, 2022
Visit Reason
The inspection was conducted in response to multiple complaints identified by numbers NJ155910, NJ156096, NJ156098, and NJ156231.
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 visit.
Complaint Details
Complaint investigation for complaints NJ155910, NJ156096, NJ156098, and NJ156231 resulted in no deficiencies; the facility was compliant.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 181
Deficiencies: 10
Oct 6, 2021
Visit Reason
Complaint survey conducted due to multiple complaint intakes regarding resident care, medication administration, staffing, environment, and infection control.
Findings
The facility was found non-compliant with multiple regulatory requirements including failure to maintain a dignified environment for residents, failure to notify responsible parties and physicians of medication changes and refusals, inadequate care and response to call lights, insufficient staffing levels, failure to provide behavioral health services and monitoring of psychotropic medications, improper food safety practices, infection control deficiencies, and failure to maintain the physical plant in good repair.
Complaint Details
Complaint Intakes #NJ148720, NJ148438, NJ148225, NJ147973, NJ147766, NJ146520, and NJ145242 triggered the survey. Issues included resident dignity, medication management, staffing shortages, behavioral health care, food safety, infection control, and environmental maintenance.
Severity Breakdown
SS=D: 4
SS=G: 1
SS=E: 3
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to maintain a dignified environment and provide timely assistance with bedpan use for residents. | SS=D |
| Failure to notify responsible parties and physicians of medication changes and refusals. | SS=D |
| Failure to develop and implement comprehensive care plans addressing medication refusal behavior. | SS=D |
| Failure to provide care and services according to professional standards, including missed medication administration and inadequate incontinent care. | SS=G |
| Failure to provide sufficient nursing staff to meet resident needs, resulting in delayed call light responses and missed care. | SS=E |
| Failure to provide necessary behavioral health services including appropriate care plans, monitoring, and non-pharmacological interventions. | SS=D |
| Failure to ensure proper monitoring and documentation of psychotropic medication use, including side effects and behavior monitoring. | SS=D |
| Failure to wear hair restraints in the kitchen and improper storage and consumption of food and personal items in food preparation areas. | SS=F |
| Failure to follow infection control procedures including improper mask wearing and inadequate hand hygiene during meal service. | SS=E |
| Failure to maintain a safe, functional, sanitary, and comfortable environment including holes in walls, water damage, disrepair of ice machines, missing baseboards, broken handrails, and malfunctioning call lights. | SS=E |
Report Facts
Resident census: 181
Sample size: 40
Staffing ratios: 21
Staffing ratios: 10
Staffing ratios: 16
Staffing ratios: 4
Medication doses missed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in relation to medication pass and staffing issues on 10/03/2021 night shift |
| RN #3 | Registered Nurse | Named in relation to medication pass and staffing issues on 10/03/2021 night shift |
| CNA #5 | Certified Nursing Assistant | Named in relation to incontinent care failure for Resident #9 |
| CNA #6 | Certified Nursing Assistant | Named in relation to Resident #5 ingesting soap incident |
| Director of Nursing | Director of Nursing | Named in relation to staffing, medication, and behavioral health deficiencies |
| Nursing Home Administrator | Administrator | Named in relation to staffing, environment, and behavioral health deficiencies |
| Physician Assistant #1 | Physician Assistant | Named in relation to medication increase for Resident #3 |
| Social Service Director | Social Service Director | Named in relation to behavioral health and medication monitoring |
| Dietary Aide #1 | Dietary Aide | Named in relation to food safety and hairnet non-compliance |
| Assistant Manager | Assistant Manager | Named in relation to food safety and hairnet non-compliance |
| Certified Nursing Assistant #11 | Certified Nursing Assistant | Named in relation to infection control mask non-compliance |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Named in relation to infection control mask non-compliance |
| Certified Nursing Assistant #10 | Certified Nursing Assistant | Named in relation to infection control mask non-compliance |
| Certified Nursing Assistant #12 | Certified Nursing Assistant | Named in relation to incontinent care failure and call bell response |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in relation to staffing shortages |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Named in relation to staffing shortages |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Named in relation to staffing shortages |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Named in relation to incontinent care failure |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in relation to staffing shortages |
Inspection Report
Complaint Investigation
Census: 185
Deficiencies: 4
Jun 2, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint intakes regarding abuse, neglect, and quality of care issues at the facility.
Findings
The facility was found not in compliance with requirements related to freedom from abuse and neglect for multiple residents, failure to provide timely incontinent care for one resident, failure to obtain resident weights per physician orders for two residents, and failure to administer medications as ordered for two residents. Interventions and staff education plans were outlined to address these deficiencies.
Complaint Details
Complaint survey based on multiple complaint intakes NJ143394, NJ144178, NJ144173, NJ143682, NJ143749, NJ143453, NJ143170, NJ141901, NJ141644, NJ141598. The complaints involved allegations of abuse, neglect, failure to provide care, and medication errors.
Severity Breakdown
SS=G: 1
SS=D: 1
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure residents were free from abuse for 3 of 5 residents investigated for abuse. | SS=G |
| Failure to provide timely incontinent care for 1 of 3 residents reviewed for incontinent care. | SS=D |
| Failure to ensure resident weights were obtained per physician's order for 2 of 5 residents investigated for weight loss. | SS=E |
| Failure to ensure medications were provided as ordered by the physician for 2 of 5 residents reviewed for medication administration. | SS=E |
Report Facts
Complaint intakes: 10
Census: 185
Sample size: 29
Residents investigated for abuse: 5
Residents with abuse findings: 3
Residents reviewed for incontinent care: 3
Residents with incontinent care deficiency: 1
Residents reviewed for weight loss: 5
Residents with weight deficiency: 2
Residents reviewed for medication administration: 5
Residents with medication administration deficiency: 2
Inspection Report
Annual Inspection
Census: 192
Deficiencies: 3
May 13, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. A COVID-19 Focused Infection Control Survey was also conducted to assess infection control compliance.
Findings
Deficiencies were cited related to failure to meet professional standards in clinical care, incomplete medication administration records, failure to obtain physician orders for specialized care, failure to follow menu plans and food safety requirements, and sanitation issues in food procurement and storage.
Severity Breakdown
SS=E: 1
SS=D: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to follow acceptable standards of clinical practice including weekly weights not obtained as ordered, incomplete medication administration records, and lack of physician orders for specialized care. | SS=E |
| Failure to ensure menus meet resident needs and substitutions were not properly approved or documented. | SS=D |
| Failure to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness, including wet food boxes, dented cans, unclean equipment, undated food items, and cracked plates. | SS=F |
Report Facts
Census: 192
Sample Size: 36
Deficiency Completion Dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding facility policy on weights and medication administration. |
| LPN Unit Manager | Licensed Practical Nurse Unit Manager | Confirmed weekly weight orders and documentation responsibilities. |
| Registered Dietician | Registered Dietician | Reviewed weights and meal substitutions, provided education on monitoring weights. |
| Director of Nursing | Director of Nursing (DON) | Provided expectations for weights and medication administration, confirmed order updates. |
| Food Service Director | Food Service Director (FSD) | Interviewed regarding food substitutions, sanitation issues, and kitchen management. |
| Cook | Cook | Interviewed regarding food preparation, substitutions, and kitchen sanitation. |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Observed pantry food and assisted with disposal of expired/undated items. |
Inspection Report
Life Safety
Deficiencies: 9
May 7, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health to assess compliance with fire safety and life safety code requirements for participation in Medicare/Medicaid.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including delayed egress door locking, exit discharge surfaces, illumination of means of egress, cooking facility fire suppression, fire alarm system installation, sprinkler system maintenance, smoke barrier door functionality, elevator emergency communication, and improper use of power strips and extension cords.
Severity Breakdown
SS=D: 4
SS=E: 2
SS=F: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Delayed egress door did not open within 15 seconds as required. | SS=D |
| Exit discharge did not provide a hard packed all-weather travel surface to the common way. | SS=D |
| Emergency illumination along means of egress could be completely shut off, failing to provide continuous emergency lighting. | SS=F |
| Fire suppression system nozzles over cooking stove were improperly positioned, not protecting against fire extension. | SS=D |
| Fire alarm system lacked audible and visible notification signals in two enclosed courtyard areas. | SS=F |
| Sprinkler system maintenance deficiencies including missing ceiling tiles and escutcheon plates allowing smoke to bypass sprinklers. | SS=F |
| Two smoke barrier doors failed to fully close when released from magnetic hold-open devices. | SS=E |
| Elevator emergency communication telephones were nonfunctional or had inaudible volume in both elevators. | SS=E |
| Power strips and extension cords were improperly used for high draw appliances, creating electrical hazards. | SS=D |
Report Facts
Deficiencies cited: 9
Delay time: 15
Date survey completed: May 7, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Maintenance staff member | Mentioned in relation to multiple findings including door locking, fire suppression nozzles, emergency lighting, sprinkler system, and fire alarm system. | |
| Maintenance Director | Mentioned in relation to fire alarm system findings and elevator emergency communication. | |
| Administrator | Notified of all findings during Life Safety Code exit conference. | |
| Environmental Director | Present during observations of fire suppression and smoke barrier door deficiencies. |
Inspection Report
Routine
Census: 201
Deficiencies: 0
Mar 8, 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 related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 203
Deficiencies: 1
Jan 20, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers (NJ00140401, NJ00139235, NJ00128264, NJ00138515) to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility failed to serve food to residents at an appetizing and safe temperature, affecting five sampled residents and 197 residents who received meals. The Dietary Director had not ensured food was served hot and had not investigated complaints of cold food.
Complaint Details
The visit was complaint-related with multiple complaint numbers cited. The facility was found non-compliant with food temperature requirements based on observations, resident interviews, and staff statements.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to serve food at an appetizing temperature affecting five sampled residents and 197 residents receiving meals. | SS=E |
Report Facts
Census: 203
Sample Size: 15
Residents affected: 5
Residents receiving meals: 197
Food temperature: 118
Food temperature: 115
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Director | Named in relation to failure to check food temperatures and investigate complaints |
Inspection Report
Abbreviated Survey
Census: 203
Deficiencies: 1
Jan 20, 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 CMS/CDC recommended practices during the COVID-19 pandemic.
Findings
The facility failed to implement proper infection control practices by allowing residents presumptive for COVID-19 to come into close contact with COVID-19 negative residents, failing to encourage residents to remain in isolation units, and failing to ensure residents wore face coverings. These deficiencies were observed on one of four units and had the potential to affect all 203 residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to use proper infection control practices to prevent spread of infections by allowing presumptive COVID-19 residents to come in close contact with COVID-19 negative residents, failure to encourage residents to remain in isolation, and failure to encourage residents to wear face coverings. | SS=F |
Report Facts
Census: 203
Sample size: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Flanagan | RN- Regional Consultant | Consultant/Instructor for staff training on infection control and COVID-19 prevention |
| RN #1 | Registered Nurse | Interviewed regarding Resident #10's mask compliance and isolation adherence |
| ADON | Assistant Director of Nurses | Interviewed about resident isolation and mask policies |
| DON | Director of Nurses | Interviewed regarding mask wearing and social distancing policies for residents |
Inspection Report
Complaint Investigation
Census: 199
Deficiencies: 2
Jan 6, 2021
Visit Reason
The inspection was conducted based on complaints NJ 142112 and NJ 142081, focusing on allegations related to inadequate ADL care and wound care.
Findings
The facility failed to provide timely and appropriate incontinence care to Resident #3 and failed to follow a physician's order for wound care for Resident #2. Immediate corrective actions were taken, including education of staff and audits to ensure compliance.
Complaint Details
The investigation was triggered by complaints NJ 142112 and NJ 142081. The deficiencies related to incontinence care and wound care were substantiated based on observations, interviews, and record reviews.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide appropriate incontinence care in a timely manner for Resident #3, contrary to facility policy. | SS=D |
| Failure to follow physician's orders for wound care for Resident #2, resulting in lack of dressing changes and risk of infection. | SS=D |
Report Facts
Sample size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Conducted body assessment for Resident #3 and provided education to nursing staff | |
| Director of Nursing | Reported on risks of not changing incontinent residents every 2 hours | |
| Unit Manager | Responsible for changing dressing of Resident #2 and reported inability to complete treatment due to high acuity | |
| CNA #1 | Certified Nursing Assistant | Reported on Resident #3's continence status and care |
Inspection Report
Complaint Investigation
Census: 198
Deficiencies: 0
Dec 22, 2020
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ139781 and NJ141900.
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.
Complaint Details
Complaint numbers NJ139781 and NJ141900 were investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 3
Inspection Report
Complaint Investigation
Census: 196
Deficiencies: 0
Nov 23, 2020
Visit Reason
The inspection visit was conducted in response to a complaint (Complaint#: NJ 141236) to assess compliance with regulatory requirements.
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 visit.
Complaint Details
Complaint#: NJ 141236. The facility was found compliant based on this complaint visit.
Inspection Report
Abbreviated Survey
Census: 195
Deficiencies: 4
Nov 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.
Findings
The facility failed to consistently implement proper infection control practices including lack of signage for isolation precautions, inconsistent use of PPE by staff, allowing presumptive COVID-19 positive residents to come in close contact with negative residents, and failure to disinfect protective face shields/eye wear after exiting COVID-19 units. Multiple staff interviews and observations confirmed confusion and non-compliance with PPE protocols and isolation signage.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to post signage indicating isolation precautions on COVID-19 units and resident rooms. | SS=E |
| Inconsistent application of personal protective equipment (PPE) by staff on units with residents on transmission-based precautions. | SS=E |
| Allowing presumptive COVID-19 positive residents to come in close contact with COVID-19 negative residents. | SS=E |
| Failure to disinfect protective face shields and goggles after exiting COVID-19 units. | SS=E |
Report Facts
Census: 195
Sample size: 3
Completion date for plan of correction: Plan of correction completion date stated as 11/30/2020.
Number of units toured: 4
14-day observation period: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager | Interviewed regarding unit mix of residents and PPE usage. | |
| Infection Preventionist (IP) | Confirmed unit status and PPE protocols, admitted staff confusion. | |
| Director of Nursing (DON) | Described cohort zones and PPE requirements. | |
| Physical Therapist (PT) | Observed wearing PPE inconsistently and interviewed about PPE use. | |
| Licensed Practical Nurse (LPN #1) | Interviewed about PPE requirements and unit status. | |
| Certified Nursing Assistant (CNA #1 and #2) | Interviewed about PPE use and awareness of quarantine status. | |
| Physician Therapy Assistant (PTA) | Observed not cleaning goggles and not wearing gowns in hallways. | |
| Nurse Practitioner (NP) | Observed wearing minimal PPE and unaware of unit status. | |
| Director of Rehabilitation (DOR) | Admitted staff confusion about resident status and PPE requirements. |
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