Deficiencies (last 6 years)
Deficiencies (over 6 years)
11.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
115% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
92% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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 health 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, legal duties of NJDHSS, and the rights of individuals to access, amend, and restrict their health information.
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
Complaint Investigation
Deficiencies: 3
Date: Aug 18, 2025
Visit Reason
The inspection was conducted based on complaint investigations regarding allegations of resident abuse, failure to report suspected abuse timely, inconsistent documentation on the Treatment Administration Record (TAR), and failure to obtain a physician's order for respiratory equipment for Resident #11.
Complaint Details
Complaint #390051 involved allegations of abuse and failure to follow nursing standards for documentation and respiratory care. The complaint was substantiated with findings of failure to report abuse timely, incomplete documentation on TAR, and lack of physician order for BiPAP use.
Findings
The facility failed to timely report allegations of resident abuse to the New Jersey Department of Health, failed to consistently document treatments on the TAR for Resident #11, and failed to obtain a physician's order for the use of a BiPAP machine for Resident #11. These deficiencies were identified through interviews, medical record reviews, and policy reviews.
Deficiencies (3)
Failed to timely report allegations of resident abuse involving misappropriation of funds and resident-to-resident verbal abuse.
Failed to consistently document treatments on the Treatment Administration Record (TAR) for Resident #11.
Failed to obtain a physician's order for Resident #11's bilevel positive airway pressure (BiPAP) machine.
Report Facts
Residents reviewed for abuse: 14
Residents reviewed for documentation: 3
Residents reviewed for respiratory care: 14
BIMS score: 11
BIMS score: 11
BIMS score: 15
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 147
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 20
Inspection Report
Renewal
Census: 130
Deficiencies: 17
Date: Nov 19, 2024
Visit Reason
A Recertification survey was conducted to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facility. Complaint investigations were also completed during this survey.
Complaint Details
Complaint numbers NJ177864 and NJ168254 were investigated during this survey. The complaint investigations were completed and deficiencies were cited accordingly.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents' call devices were accessible, failure to provide resident bathing choice, failure to be free from physical restraints, failure to complete required background checks for new hires, medication administration errors, and deficiencies in life safety code compliance such as self-closing doors and fire alarm systems.
Deficiencies (17)
Facility failed to ensure the resident's call device was readily accessible.
Facility failed to ensure residents' bathing choice was provided.
Facility failed to ensure residents were free from physical restraints without physician orders.
Facility failed to complete criminal background checks and reference checks for newly hired staff prior to employment.
Facility failed to ensure medication was administered according to physician's orders.
Facility failed to maintain complete and accessible medical records for residents.
Facility failed to ensure exit doors with self-closing devices were kept in closed position.
Facility failed to ensure exit signs had continuous illumination and were served by emergency lighting system.
Facility failed to maintain sprinkler system and conduct required monthly fire pump tests.
Facility failed to conduct monthly visual inspections of portable fire extinguishers.
Facility failed to conduct fire drills with required frequency and documentation.
Facility failed to maintain smoke detection sensitivity testing on smoke detectors.
Facility failed to maintain ventilation systems in resident bathrooms.
Facility failed to maintain sprinkler system and fire alarm system in accordance with NFPA standards.
Facility failed to maintain electrical equipment testing and maintenance.
Facility failed to maintain corridor doors and fire rated corridor walls to resist passage of smoke.
Facility failed to store compressed oxygen cylinders properly to prevent tipping and rupture.
Report Facts
Census: 130
Sample Size: 25
Deficiencies cited: 19
Completion Date: Dec 9, 2024
Completion Date: Dec 6, 2024
Completion Date: Dec 10, 2024
Completion Date: Dec 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding resident showers and restraint use. |
| Registered Nurse #1 | Registered Nurse | File reviewed for background checks and reference checks. |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | File reviewed for background checks and reference checks. |
| Director of Nursing (DON) | Director of Nursing | Oversaw re-education of nursing staff on policies and procedures. |
| Maintenance Director | Maintenance Director | Conducted inspection of self-closing doors and fire safety equipment. |
Inspection Report
Routine
Deficiencies: 7
Date: Nov 19, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to keep resident call bells within reach, failure to provide scheduled showers, improper use of physical restraints, incomplete pre-employment checks, medication administration delays, failure to document urinary catheter output, and incomplete psychiatric consult documentation.
Deficiencies (7)
Failure to ensure resident's call device was readily accessible for 1 of 25 residents.
Failure to ensure residents' bathing choice of a day shower was provided for 1 of 1 resident.
Failure to ensure a resident was free from a physical restraint without physician order for 1 of 2 residents reviewed for restraints.
Failure to complete reference checks, criminal background checks, and physical examinations for new hires prior to employment.
Failure to ensure a resident received medication (Abemaciclib) according to physician's order for breast cancer.
Failure to record and document urinary output of resident with indwelling urinary catheter per physician orders.
Failure to maintain complete and readily accessible medical records, specifically missing psychiatric consult notes for 1 of 28 residents.
Report Facts
Residents reviewed for call bell accessibility: 25
Residents reviewed for bathing choice: 1
Residents reviewed for restraints: 2
New employees reviewed: 10
Scheduled showers missed: 9
Medication doses missed: 5
Residents reviewed for urinary catheter output: 2
Psychiatric consult notes missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Acknowledged call bell should be within reach and assessed Resident #99 with seatbelt restraint |
| Licensed Practical Nurse Supervisor | Licensed Practical Nurse Supervisor | Interviewed regarding shower schedules and resident bathing |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding shower schedules and resident bathing |
| Human Resources Director | Human Resources Director | Confirmed missing reference and background checks for new hires |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Acknowledged deficiencies and met with survey team multiple times |
| Interim Director of Nursing | Interim Director of Nursing | Acknowledged call bell placement, medication delays, and met with survey team |
| Registered Nurse Supervisor | Registered Nurse Supervisor | Interviewed about psychiatric consult visits and medical record documentation |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed medication administration for Resident #131 |
| Resident #13 Medical Doctor | Medical Doctor | Interviewed regarding missed medication doses for Resident #131 |
Inspection Report
Complaint Investigation
Census: 135
Deficiencies: 1
Date: Jul 12, 2024
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers (NJ172636, NJ175486, NJ175522, NJ175524, NJ175526) to assess compliance with federal and state regulations for long-term care facilities.
Complaint Details
The visit was complaint-related with multiple complaint numbers cited. The facility was found deficient in meeting minimum staffing ratios, which was substantiated by review of staffing reports and documentation.
Findings
The facility was found not in compliance with New Jersey Administrative Code standards due to failure to maintain minimum direct care staff-to-resident ratios on 14 of 28 day shifts, potentially affecting all residents. The facility submitted a plan of correction addressing staffing shortages and recruitment efforts.
Deficiencies (1)
Failure to ensure minimum direct care staff-to-resident ratios as mandated by New Jersey law on 14 of 28 day shifts.
Report Facts
Census: 135
Deficient day shifts: 14
CNA staffing shortages: 5
CNA staffing shortages: 9
CNAs hired: 6
Staffing correction completion date: Plan of correction completion date August 12, 2024.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 21, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to clarify and administer a physician's order for Paxlovid for a resident with COVID-19, and failure to implement infection control and outbreak response plans to prevent the spread of COVID-19 in the facility.
Complaint Details
The complaint investigation revealed that Resident #4 did not receive timely Paxlovid treatment due to unclear physician orders and communication breakdowns, resulting in death. Additionally, the facility failed to initiate contact tracing and monitoring for COVID-19 exposures among residents and staff, contributing to a large outbreak. The Immediate Jeopardy was identified on 11/16/2023 and removed on 11/20/2023 after an acceptable removal plan was implemented.
Findings
The facility failed to clarify a physician's order for Paxlovid resulting in delayed treatment and death of Resident #4. The facility also failed to implement effective infection prevention and control measures, including contact tracing and monitoring of residents and staff exposed to COVID-19, leading to a widespread outbreak affecting many residents and staff.
Deficiencies (2)
Failure to clarify and timely administer Paxlovid order for Resident #4, resulting in delayed treatment and death.
Failure to implement outbreak response plan and conduct contact tracing for COVID-19 positive staff and residents, resulting in widespread transmission.
Report Facts
Residents tested positive for COVID-19: 36
Staff tested positive for COVID-19: 24
Resident deaths: 7
Residents exposed by CNA #1: 7
Residents exposed by CNA #2: 2
Paxlovid order clarification attempts: 3
Paxlovid administration delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to failure to clarify Paxlovid order and delayed treatment of Resident #4 | |
| Licensed Practical Nurse (LPN #1) | Described medication order process and documentation practices | |
| Licensed Practical Nurse (LPN #2) | Clarified Paxlovid order and described delays in medication delivery | |
| Pharmacy Representative | Reported delays and communication issues regarding Paxlovid order | |
| Physician (MD) of Resident #4 | Provided expectations for timely medication administration and impact of delay | |
| Infection Preventionist (IP) | Responsible for infection control program and outbreak response; failed to implement outbreak plan fully | |
| Licensed Nursing Home Administrator (LNHA) | Responsible for facility operations and outbreak management; aware of outbreak but delayed plan implementation | |
| Certified Nursing Assistant (CNA #1) | COVID-19 positive staff who worked while symptomatic and exposed residents | |
| Certified Nursing Assistant (CNA #2) | COVID-19 positive staff who worked while symptomatic and exposed residents |
Inspection Report
Routine
Capacity: 73
Deficiencies: 10
Date: Jul 17, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 07/05/2023 through 07/07/2023 to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was found noncompliant with several Life Safety Code requirements including egress door accessibility, illumination of means of egress, exit signage, cooking facilities inspection, sprinkler system installation and maintenance, portable fire extinguisher inspection and installation, HVAC ventilation maintenance, electrical system testing, and emergency generator safety features.
Deficiencies (10)
Failed to provide 1 of 10 designated exit discharge doors readily accessible and free of obstructions or impediments to full instant use in case of fire or other emergencies.
Failed to ensure continuous illumination for 2 of 9 designated exit discharges so that failure of any single lighting unit did not result in illumination level less than 0.2 ft-candle.
Failed to ensure illuminated exit signs in six locations to clearly identify the exit access path to reach an exit discharge door.
Failed to inspect the range-hood fire suppression system semi-annually as required by NFPA 96.
Failed to properly install sprinklers and provide fire sprinkler coverage to all areas of the facility as required.
Failed to comply with inspection and testing requirements for sprinkler system; missed quarterly inspections resulting in 12 months gap.
Failed to perform monthly examination for 2 of 28 portable fire extinguishers, inspect 1 of 28 annually, and install 11 of 28 extinguishers within required height.
Failed to ensure proper maintenance of 4 of 9 resident bathroom exhaust ventilation systems.
Failed to ensure annual electrical outlet testing was conducted on the electrical system.
Failed to install a remote manual stop station for the emergency generator as required.
Report Facts
Designated exit discharge doors: 10
Designated exit discharge doors with illumination issues: 2
Exit signs missing illumination: 6
Range-hood fire suppression inspections missed: 1
Resident sleeping rooms: 73
Portable fire extinguishers inspected: 28
Portable fire extinguishers with installation height issues: 11
Resident bathroom exhaust systems tested: 9
Resident bathroom exhaust systems not functioning: 4
Electrical outlet testing missed year: 2022
Emergency generator inspection date: Jul 5, 2023
Inspection Report
Routine
Deficiencies: 5
Date: Jul 17, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding accurate resident assessments, care plan development, discharge documentation, pharmaceutical services, and medication administration.
Findings
The facility was found deficient in accurately coding Minimum Data Set (MDS) assessments for restraints, developing individualized care plans reflecting significant weight changes and current orders, completing physician discharge summaries, ensuring timely availability and proper documentation of medication administration, and administering appropriate antibiotics based on lab sensitivity results.
Deficiencies (5)
Failure to accurately code the Minimum Data Set (MDS) for physical restraints used for 3 of 5 residents.
Failure to develop complete and individualized care plans within 7 days reflecting significant weight changes and current orders for 3 of 6 residents.
Failure to ensure physician discharge summaries were completed for 2 of 3 closed records reviewed.
Failure to provide pharmaceutical services ensuring timely medication ordering, receipt, physician order verification, and documentation for Resident #18.
Failure to ensure antibiotic was administered effectively to treat a resident with UTI due to resistance to prescribed antibiotic.
Report Facts
Residents reviewed for MDS coding accuracy: 5
Residents reviewed for care plan deficiencies: 6
Residents reviewed for discharge summary deficiencies: 3
Residents reviewed for unnecessary medication: 5
Duration of antibiotic order: 10
Weight measurements: 155
Weight measurements: 139
Medication tablets received: 30
Medication tablets dispensed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed preparing medication and admitting to administering incorrect dose of Haldol | |
| Registered Nurse/In-service Coordinator (RN/IC) | Interviewed regarding medication ordering and administration issues | |
| Director of Nursing (DON) | Provided clarifications on MDS coding, care plans, medication availability, and antibiotic stewardship | |
| Licensed Nursing Home Administrator (LNHA) | Participated in interviews regarding medication and care plan deficiencies | |
| Registered Dietitian (RD) | Interviewed regarding nutrition care plans and weight loss documentation |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 5
Date: Jun 26, 2023
Visit Reason
Complaint survey conducted on 6/15/23, 6/20/23, and 6/26/23 to investigate multiple complaints regarding resident care and facility compliance.
Complaint Details
Complaint numbers NJ160552, NJ164625, NJ164644, NJ164690, NJ164724 triggered the investigation. Immediate jeopardy was identified related to resident care failures and was removed after corrective actions were implemented.
Findings
The facility was found not in substantial compliance with federal requirements due to immediate jeopardy situations related to failure to notify physicians of changes in resident condition, failure to provide adequate care and oversight, neglect, and failure to maintain minimum staffing ratios. Deficiencies included failure to communicate care needs, failure to monitor residents properly, and medication administration issues.
Deficiencies (5)
Failure to notify the primary care physician and related practitioners of significant changes in resident condition, resulting in immediate jeopardy.
Failure to provide care free from abuse and neglect, including leaving a resident unattended during a medical emergency.
Failure to provide services meeting professional standards, including failure to notify appropriate staff and follow policies during resident condition changes.
Failure to label and store drugs and biologicals properly, including leaving medications at the bedside and signing medication records without administration.
Failure to maintain minimum direct care staff-to-resident ratios as mandated by the State of New Jersey.
Report Facts
Census: 114
Sample Size: 6
Deficient CNA staffing shifts: 5
Required CNA staffing: 14
Actual CNA staffing: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to failure to notify physician, leaving resident unattended, and failure to follow job duties |
| LPN #3 | Licensed Practical Nurse | Named in medication administration deficiency for leaving medications at bedside and signing MAR without administration |
| Director of Nursing | Director of Nursing (DON) | Responsible for monitoring LPN #1 and overseeing quality assurance |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 26, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging failure to properly communicate and address a resident's change in condition (seizure activity) and failure to notify the physician and appropriate staff.
Complaint Details
Complaint NJ00164724 involved allegations that the facility failed to communicate and respond appropriately to Resident #2's seizure activity/change in condition, failed to notify the PCP timely, and left the resident unattended by licensed nursing staff. The complaint was substantiated with findings of Immediate Jeopardy that was later removed after corrective actions.
Findings
The facility failed to immediately address Resident #2's seizure activity, notify the Primary Care Physician and nursing staff, and left the resident unattended by licensed nurses, resulting in an Immediate Jeopardy situation. Additionally, medication administration practices for Resident #1 were found deficient due to leaving medications unattended and signing off without administration.
Deficiencies (4)
Failure to communicate change in condition and notify physician immediately for Resident #2's seizure activity.
Failure to provide necessary services to prevent neglect of Resident #2 after seizure activity.
Failure to follow professional nursing standards including notification and supervision protocols during Resident #2's seizure activity.
Failure to ensure medication administration according to physician orders for Resident #1; medications left unattended and signed off without administration.
Report Facts
Deficiencies cited: 4
Seizure duration: 2
Medication administration times: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to failure to notify physician and leaving Resident #2 unattended during seizure activity. |
| QACNA | Quality Assurance Certified Nursing Assistant | Involved in initial response to Resident #2's seizure and monitoring after LPN #1 left. |
| LPN #3 | Licensed Practical Nurse | Named in medication administration deficiency for Resident #1. |
| DON #1 | Director of Nursing | Wrote Employee Warning Report regarding LPN #1's misconduct. |
| PCP | Primary Care Physician | Notified late via text message about Resident #2's seizure activity. |
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 1
Date: Mar 25, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers (NJ153425, NJ153428, NJ151815, and NJ151607) to determine compliance with New Jersey Administrative Code 8:39 for licensure of long-term care facilities.
Complaint Details
Complaint numbers NJ153425, NJ153428, NJ151815, and NJ151607 were investigated. The facility was found deficient in staffing ratios, which had the potential to affect all residents. The complaint was substantiated based on interviews, document review, and NJDOH memo dated 01/28/2021.
Findings
The facility was found not in substantial compliance due to failure to meet minimum staffing ratios for certified nursing assistants and total staff on multiple shifts during the review periods from January 16-29, 2022 and March 6-19, 2022. Staffing shortages were confirmed through document review and interviews, with the Administrator acknowledging the shortages and efforts to recruit and incentivize staff.
Deficiencies (1)
Failure to ensure staffing ratios were met for 29 out of 56 shifts reviewed, including CNA staffing shortages on 14 of 14 day shifts and total staff shortages on some overnight and evening shifts.
Report Facts
Census: 127
Shifts with staffing deficiencies: 29
Day shifts deficient in CNA staffing: 14
Overnight shifts deficient in total staff: 1
Required CNAs on 01/16/2022 day shift: 15
Actual CNAs on 01/16/2022 day shift: 12
Required total staff on 01/17/2022 overnight shift: 9
Actual total staff on 01/17/2022 overnight shift: 8
Required CNAs on 03/06/2022 day shift: 16
Actual CNAs on 03/06/2022 day shift: 11
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 4
Date: Dec 3, 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 respiratory/tracheostomy care, dialysis care, and pharmacy services including medication administration and controlled substances management. Additionally, the facility was found deficient in maintaining required minimum direct care staff-to-resident ratios.
Deficiencies (4)
Facility failed to ensure therapy was administered in accordance with physician's orders for respiratory care.
Facility failed to observe, monitor, assess and document care of a hemodialysis resident's access site.
Facility failed to maintain controlled medications in a manner that would decrease the possibility of loss or diversion; discrepancies found in narcotic counts and documentation.
Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state regulations.
Report Facts
Census: 120
Sample Size: 28
Deficiencies cited: 4
Staffing Deficiencies: 14
Staffing Deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Mentioned in relation to respiratory therapy deficiency and medication administration | |
| Director of Nursing (DON) | Involved in addressing respiratory therapy and dialysis care deficiencies and staffing issues | |
| Licensed Nursing Home Administrator (LNHA) | Involved in addressing respiratory therapy deficiency | |
| Registered Nurse (RN) | Mentioned in relation to medication cart and narcotic count deficiencies | |
| Administrator | Discussed staffing ratio concerns with surveyor |
Inspection Report
Life Safety
Census: 121
Capacity: 159
Deficiencies: 5
Date: Dec 3, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/03/2021 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety code standards.
Findings
The facility was found to be in noncompliance with several life safety code requirements including emergency lighting, sprinkler system installation and maintenance, fire pump testing, generator transfer time certification, and improper use of power strips. Corrective actions and plans of correction were documented for each deficiency.
Deficiencies (5)
Failed to provide battery backup emergency light above the emergency generator's transfer switch independent of building electrical system.
Incomplete sprinkler coverage in multiple stairwells under the first accessible landing.
Failed to perform monthly electric fire pump churn test as required.
Failed to certify generator transfer time within required 10 seconds during monthly tests.
Use of multi-outlet power strip for high draw electrical appliances in patient care vicinity.
Report Facts
Certified beds: 159
Census: 121
Deficiencies cited: 5
Completion dates: Dec 4, 2021
Completion dates: Mar 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified deficiencies and participated in interviews regarding emergency lighting, sprinkler coverage, fire pump testing, generator transfer time, and electrical equipment. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 3, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, and facility policies at Mohawk Meadows nursing home.
Findings
The facility was found deficient in multiple areas including improper oxygen therapy administration not following physician orders, failure to monitor and document hemodialysis access site assessments, and inadequate control and documentation of controlled medications in medication carts.
Deficiencies (3)
Failure to ensure oxygen therapy was administered according to physician's orders for Resident #46.
Failure to observe, monitor, assess, and document care of a hemodialysis resident's access site for Resident #121.
Failure to maintain controlled medications securely and accurately document narcotic counts in medication cart.
Report Facts
Oxygen flow rate discrepancy: 1.5
Medication discrepancies: 3
Medication cart inspected: 1
Residents reviewed for dialysis care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Assigned nurse who confirmed oxygen setting discrepancy and oxygen saturation for Resident #46 | |
| Director of Nursing (DON) | Confirmed concern about oxygen therapy not following physician's order | |
| Licensed Nursing Home Administrator (LNHA) | Confirmed concern about oxygen therapy not following physician's order | |
| Registered Nurse (RN) | Assigned to medication cart with narcotic count discrepancies | |
| Administrator | Addressed concerns about controlled substances and narcotic counts |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Date: Jul 19, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ145280, NJ145251, and NJ144172.
Complaint Details
Complaint numbers NJ145280, NJ145251, and NJ144172 were investigated and found to be unsubstantiated as the facility was 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: 7
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 0
Date: Mar 3, 2021
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Complaint Details
The survey was complaint-based and the facility was found compliant; no deficiencies were cited.
Findings
The facility was found to be in compliance with the regulatory requirements based on this complaint survey.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 110
Deficiencies: 0
Date: Jan 15, 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.
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: 9
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaint number NJ00135882.
Complaint Details
Complaint #: NJ00135882. The facility was found compliant based on this complaint survey.
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: 6
Inspection Report
Routine
Census: 107
Deficiencies: 0
Date: Nov 17, 2020
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 recommended practices for 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: 3
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