Inspection Reports for Health Center At Galloway The

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Complaint investigation and standard survey to assess compliance with federal and state regulations including resident rights, reporting of alleged violations, care planning, staffing, medication management, food safety, and life safety code.

The facility was found not in substantial compliance with multiple regulatory requirements including failure to maintain resident dignity during meal assistance, failure to timely report alleged abuse and injuries, inadequate comprehensive care plans, insufficient RN and CNA staffing, failure to follow psychotropic medication protocols, food safety violations, fire safety and life safety code deficiencies including fire alarm system issues, corridor door malfunctions, elevator safety, smoking area violations, emergency preparedness plan deficiencies, and electrical system maintenance lapses.

The visit was complaint-related with multiple complaint staffing weeks reviewed showing deficient CNA staffing ratios on numerous day shifts and deficient RN coverage on multiple days. The facility failed to maintain required minimum direct care staff to resident ratios as mandated by the state of New Jersey.

The inspection was conducted as a complaint investigation based on complaints NJ171525, NJ171831, and NJ171833.

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 numbers NJ171525, NJ171831, and NJ171833 were investigated and the facility was found to be in substantial compliance.

The inspection was conducted based on complaints NJ00171580 and NJ00171582 to investigate the facility's compliance with care plan requirements and staffing ratios.

The facility was found not in substantial compliance due to failure to develop and implement a comprehensive person-centered care plan for a resident involved in incidents, and failure to maintain required minimum staffing ratios on 11 of 14 day shifts.

Complaint numbers NJ00171580 and NJ00171582 triggered the visit. The facility was found not in substantial compliance based on these complaints.

Complaint investigation and standard survey to assess compliance with federal and state regulations related to medication administration, staffing, infection control, and life safety.

The facility was found not in substantial compliance with requirements, citing deficiencies in medication administration, staffing ratios, infection prevention, and life safety code compliance. Specific issues included failure to administer physician-prescribed medications, inadequate CNA and RN staffing levels, improper storage of respiratory equipment, unlabeled enteral feeding bottles, unprotected low voltage wiring, non-fire rated linen chute doors, and lack of annual fire door inspections.

Complaint investigation included multiple complaint numbers NJ 152080, NJ 152965, NJ 153842, NJ 160360, NJ 165072, NJ 1650272, NJ 166760, NJ 166781. The investigation found substantiated deficiencies related to medication administration, staffing, infection control, and life safety.

The inspection was conducted based on Complaint #NJ 156177 to investigate allegations related to resident dignity and rights violations at the facility.

The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, due to failure to maintain a resident's dignity by placing Resident #2 in a common area (Dining Room) without privacy after an altercation with another resident. This practice violated the resident's rights and facility policy.

Complaint #NJ 156177 was substantiated. The facility failed to maintain Resident #2's dignity and violated the policy titled 'Resident Rights' by placing the resident in the Dining Room without privacy after a resident-to-resident altercation.

The inspection was conducted as a complaint survey based on complaints NJ149467 and NJ150344 regarding staffing ratios at the facility.

The facility was found not in substantial compliance with New Jersey Administrative Code 8:39 due to failure to meet minimum staffing ratios for certified nurse aides on multiple day and evening shifts, potentially affecting all residents. Immediate corrective actions were taken and plans for ongoing monitoring were established.

Complaint #: NJ149467 and NJ150344. The complaint was substantiated as the facility failed to meet minimum staffing ratios as required by New Jersey law.

The facility was surveyed for compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities, including resident rights, safe environment, bowel/bladder care, respiratory care, food safety, and staffing requirements.

The facility was found not in substantial compliance with multiple regulatory requirements including failure to maintain resident dignity during transport, failure to maintain a clean and sanitary environment, failure to obtain physician orders for catheter care, failure to follow respiratory care orders, failure to maintain food safety standards, and failure to meet minimum direct care staffing ratios.

A Life Safety Code Survey was conducted by the New Jersey Department of Health on 08/16/2021 to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 NFPA 101 Life Safety Code for existing health care occupancy.

The facility was found noncompliant with emergency lighting requirements in the electrical room with the emergency generator transfer switch, failure to maintain required clearance around electrical panels due to combustible storage, and failure to ensure the automatic sprinkler system was inspected/tested at the required 5-year interval. Corrective actions and audits were planned for each deficiency.

The inspection was conducted as a complaint investigation based on complaints NJ 144188, NJ 145512, and NJ 145811 regarding the facility's compliance with food service regulations.

The facility failed to serve food timely and maintain food at safe and appetizing temperatures, violating the facility's food preparation policy. Food temperatures for cold items were above 41°F and hot items below 135°F, which could potentially cause resident illness, though no residents reported related issues during the inspection period.

Complaint investigation based on complaints NJ 144188, NJ 145512, and NJ 145811. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.

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.

The inspection was conducted based on complaints NJ00140946, NJ00131090, and NJ00138845 to determine compliance with 42 CFR Part 483, Subpart B for Long Term Care facilities.

The facility failed to notify the resident's responsible party/power of attorney of changes in medication and therapy services for one of five residents reviewed. Additionally, the facility failed to ensure medication and treatment carts were locked when unattended, posing a risk of unauthorized access.

Complaint survey based on complaints NJ00140946, NJ00131090, and NJ00138845. The facility was found not in compliance with notification requirements and medication cart security.

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.

The facility failed to ensure that 5 staff members wore face masks appropriately while in the building, potentially exposing all 99 residents to COVID-19. Staff were observed wearing masks under the chin or not at all, contrary to CDC and NJDOH guidelines.

The inspection was conducted as a complaint investigation based on complaint # NJ 141439.

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 # NJ 141439 was investigated and the facility was found to be in substantial compliance.