Inspection Reports for New Vista Nursing and Rehabilitation Center
NJ, 07104
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
17.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
237% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
262 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS regarding the use and disclosure of their medical information and their rights related to that information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individual rights to access and control their information, and 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
Routine
Deficiencies: 5
Date: Jul 22, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, physician documentation, pharmaceutical services, medication error rates, and food safety standards at New Vista Nursing & Rehabilitation Center.
Findings
The facility was found deficient in ensuring residents had accessible call lights, timely physician documentation, accurate pharmaceutical services including controlled substance management, and proper medication administration with an error rate exceeding 5%. Additionally, food storage and kitchen sanitation practices were inadequate, posing risks for foodborne illness.
Deficiencies (5)
Failure to ensure residents' call devices were readily accessible, affecting 3 of 7 residents reviewed.
Failure to ensure residents' primary physician signed and dated monthly physician orders and progress notes for 2 of 35 residents over a 3-month period.
Failure to provide pharmaceutical services in accordance with professional standards, including medication errors and inaccurate controlled substance inventory documentation.
Medication administration error rate of 6.25%, exceeding the 5% threshold, including insulin administration timing and incomplete medication dosing documentation.
Failure to store potentially hazardous foods properly and maintain kitchen environment and equipment in a sanitary manner.
Report Facts
Residents reviewed for call light accessibility: 7
Residents reviewed for physician documentation: 35
Medication carts inspected: 6
Residents observed during medication administration: 5
Medication administration opportunities observed: 32
Medication administration errors observed: 2
Temperature in dry storage room: 78
Ice buildup thickness: 3
Dents on food cans: 4
Dents on food cans: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration errors including insulin timing and medication documentation |
| RN #1 | Registered Nurse | Present during medication cart inspections and involved in controlled substance inventory discrepancies |
| CNA #1 | Certified Nurse Assistant | Interviewed regarding call light accessibility for Resident #24 |
| CNA #2 | Certified Nurse Assistant | Interviewed regarding call light accessibility for Residents #88 and #140 |
| DON | Director of Nursing | Interviewed regarding call light policy, physician documentation, medication errors, and medication administration procedures |
| ADON | Assistant Director of Nursing | Interviewed regarding medication error investigations and call light accessibility |
| LNHA | Licensed Nursing Home Administrator | Met with survey team to discuss deficiencies and corrective actions |
| NUM | Nurse Unit Manager | Interviewed regarding missing physician documentation |
| CP #1 | Consultant Pharmacist | Interviewed regarding medication administration observations and policies |
| FSD | Food Services Director | Present during kitchen and food storage observations |
| RN #2 | Registered Nurse | Interviewed regarding medication cart and medication administration for Resident #212 |
| LPN #2 | Licensed Practical Nurse | Observed administering medications and interviewed regarding medication supply issues |
Inspection Report
Routine
Census: 262
Deficiencies: 7
Date: Mar 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, grievance resolution, abuse reporting and investigation, medical appointment follow-up, medication administration documentation, and facility environment including linen supply.
Findings
The facility was found deficient in multiple areas including incomplete POLST documentation for residents, failure to resolve grievances, failure to timely report and investigate abuse and misappropriation allegations, failure to ensure follow-up medical appointments post-surgery, incomplete medication administration documentation, and inadequate linen supplies for resident care.
Deficiencies (7)
Failure to ensure Practitioner Orders for Life-Sustaining Treatment (POLST) forms were complete with date and physician signature for three residents.
Failure to resolve grievances related to misappropriation of funds and transportation concerns for two residents.
Failure to timely report three allegations of abuse and one allegation of misappropriation to the state survey agency within two hours.
Failure to properly investigate two allegations of abuse and one incident of misappropriation of property.
Failure to ensure a follow-up medical appointment was identified and implemented following a surgical procedure for one resident.
Failure to maintain complete and accurate medication administration records, including documentation of medication administration and availability for one resident.
Failure to ensure adequate linen supplies including towels and washcloths for resident care for two residents and the entire facility census.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 2
Facility census: 262
Residents on unit 3E: 46
Residents on unit 3E: 47
Residents on third floor E and W: 46
Residents on third floor E and W: 47
Residents on fourth floor E and W: 46
Residents on fourth floor E and W: 48
Residents on fifth floor E and W: 47
Residents on fifth floor E and W: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker 3 | Social Worker | Interviewed regarding incomplete POLST documentation |
| Licensed Practical Nurse 1 | LPN | Interviewed regarding unclear CPR choice for resident |
| Registered Nurse 3 | RN | Interviewed regarding incomplete POLST documentation |
| Social Worker 2 | Social Worker | Confirmed incomplete POLST form |
| Social Worker 3 | Social Worker | Interviewed regarding resident code status |
| Social Services Director | SSD | Confirmed process for POLST completion and grievance binder |
| Administrator | Administrator | Stated expectation for POLST completion |
| Director of Nursing | DON | Explained POLST follow-up process and acknowledged deficiencies |
| Social Worker 5 | Social Worker | Named in grievance and abuse reporting deficiencies |
| Licensed Practical Nurse 6 | LPN | Interviewed regarding abuse reporting |
| Licensed Practical Nurse 5 | LPN | Interviewed regarding abuse reporting and linen supply |
| Director of Building Services | Director of Building Services | Explained linen disappearance |
| Certified Nursing Assistant 1 | CNA | Reported linen shortages |
| Certified Nursing Assistant 4 | CNA | Reported linen shortages |
| Housekeeping Aide 2 | Housekeeping Aide | Explained linen cart distribution |
| Unit Clerk | Unit Clerk | Interviewed regarding missed surgical follow-up appointment |
| Registered Nurse Supervisor | RN Supervisor | Confirmed missed surgical follow-up appointment and medication documentation expectations |
| Licensed Practical Nurse 8 | LPN | Reported medication availability and documentation issues |
Inspection Report
Complaint Investigation
Census: 267
Deficiencies: 1
Date: Apr 17, 2024
Visit Reason
The inspection was conducted based on complaints NJ00171577, NJ00172524, and NJ00172733 to investigate compliance with federal and state regulations for long term care facilities.
Complaint Details
Complaint investigation for NJ00171577, NJ00172524, and NJ00172733. The facility was found deficient in staffing ratios but was later found in compliance after correction.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 regarding mandatory access to care due to failure to maintain required minimum staff-to-resident ratios on 11 of 14 day shifts. The facility submitted a plan of correction and later demonstrated correction of the deficiency.
Deficiencies (1)
Failure to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 11 of 14 day shifts.
Report Facts
Census: 267
Deficient day shifts: 11
Certified Nurse Aides (CNAs) required: 34
Certified Nurse Aides (CNAs) present: 28
Date of correction completion: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in plan of correction and re-education on staffing mandate. | |
| Director of Nursing | Named in plan of correction and re-education on staffing mandate. | |
| Staffing Coordinator | Named in plan of correction and re-education on staffing mandate. |
Inspection Report
Annual Inspection
Census: 273
Capacity: 340
Deficiencies: 41
Date: Feb 6, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint #s: NJ153991, #162696, #162723, #162811, #165585, #167108, #167957, and #168318. Complaint # NJ167957 and NJ162723 are referenced in findings related to food temperature and infection control.
Findings
Deficiencies were cited in multiple areas including resident rights, advance directives, safe environment, employee credential verification, complaint reporting, care planning, medication administration, infection control, staffing, and life safety code compliance.
Deficiencies (41)
Facility failed to serve all residents seated at a table their lunch trays in a timely manner.
Facility failed to ensure residents or representatives were offered the opportunity to formulate an advance directive.
Facility failed to provide a safe, comfortable, clean, and homelike environment; observed dirty fan, broken nightstand, and commode in dining area.
Facility failed to verify licensed staff credentials upon hire prior to date of hire for five licensed staff.
Facility failed to report an alleged violation involving injury of unknown source to the state agency within required timeframe.
Facility failed to complete a thorough investigation of an injury of unknown source for one resident.
Facility failed to provide a care plan addressing anticoagulant use, pain, smoking, and palliative care for four residents.
Medication administration observed not in accordance with manufacturer instructions; resident did not rinse mouth after inhaled medication.
Facility failed to ensure oxygen therapy orders and care plans were accurate and complete for three residents.
Facility failed to notify the Office of the State Long-Term Care Ombudsman of resident hospital transfer for one resident.
Facility failed to maintain complete medical records including discharge summaries for two residents.
Facility failed to ensure that expired medications were removed from active inventory and medication labeling was accurate.
Facility failed to maintain safe food handling and sanitation practices in kitchen including unlabeled food, unwashed lettuce, dirty equipment, and improper storage.
Facility failed to ensure hand hygiene was performed correctly by staff during wound care and medication administration.
Facility failed to ensure COVID-19 testing was conducted according to CDC guidance during outbreak for residents and staff.
Facility failed to ensure physician face-to-face visits were conducted at least every 60 days and documented for one resident.
Facility failed to develop and implement comprehensive care plans addressing residents' medical, physical, mental, and psychosocial needs for four residents.
Facility failed to ensure medication administration and care were provided according to professional standards for two residents.
Facility failed to ensure patency monitoring and documentation of urinary catheters for two residents.
Facility failed to ensure oxygen therapy was administered according to physician orders and professional standards for three residents.
Facility failed to provide written notification of hospital transfer to the Office of the State Long-Term Care Ombudsman for one resident.
Facility failed to ensure accurate MDS coding for oxygen therapy and influenza vaccination for three residents.
Facility failed to ensure residents' influenza and pneumococcal immunization status was documented including consent or refusal for four residents.
Facility failed to ensure annual performance reviews were completed for five Certified Nursing Aides.
Facility failed to ensure non-certified Nurse Aides did not work beyond 120 days without enrollment in approved training program.
Facility failed to ensure criminal background checks were completed prior to date of hire for four newly hired employees.
Facility failed to ensure new employees received health history and physical examination within required timeframe for six employees.
Facility failed to ensure hand hygiene was performed correctly by staff and surgical masks were not stored properly during wound care and medication administration.
Facility failed to ensure expired and discontinued medications were removed from active inventory and medication labeling was accurate.
Facility failed to ensure food was served at safe and appetizing temperatures during meal service.
Facility failed to ensure proper kitchen sanitation, food storage, and food handling practices to prevent foodborne illness.
Facility failed to ensure medical records were complete and readily accessible including documentation of ADL care and discharge summaries for two residents.
Facility failed to ensure antibiotic stewardship program was implemented with appropriate tracking, feedback, and reporting.
Facility failed to ensure influenza and pneumococcal immunizations were offered, administered, or declined with proper documentation for multiple residents.
Facility failed to ensure minimum direct care staff to resident ratios were met for Certified Nursing Aides and total staff on multiple shifts.
Facility failed to ensure non-certified Nurse Aides were enrolled in approved training programs within required timeframes.
Facility failed to ensure new employees received physical examinations or nursing assessments within required timeframes.
Facility failed to ensure smoke detectors were installed at least 36 inches away from air diffusers in corridors.
Facility failed to complete smoke detection sensitivity testing for all smoke detectors every two years.
Facility failed to ensure linen chute door was self-closing and latched properly.
Facility failed to ensure smoking area contained a metal self-closing container for cigarette disposal and was kept clean.
Report Facts
Deficient CNA staffing days: 14
Deficient CNA staffing days: 7
Deficient CNA staffing days: 4
Census: 273
Total licensed capacity: 340
Number of residents in sample: 38
Number of staff files reviewed: 10
Number of CNAs reviewed: 5
Number of smoke detectors: 520
Number of smoke barrier walls: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Observed medication administration not following manufacturer instructions. | |
| Certified Nursing Assistant #3 | Observed improper hand hygiene during resident care. | |
| Licensed Practical Nurse #2 | Observed improper hand hygiene during medication administration. | |
| Licensed Practical Nurse #1 | Observed improper storage of surgical mask during resident care. | |
| Director of Nursing | Interviewed regarding staffing and credentialing deficiencies. | |
| Human Resources Manager | Interviewed regarding hiring and credentialing processes. | |
| Director of Activities | Interviewed regarding non-certified nurse aide staffing. | |
| Food Service Director | Interviewed regarding food temperature and kitchen sanitation. | |
| Plant Manager | Interviewed regarding fire safety and smoke detector issues. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 6, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to ensure physician face-to-face visits for residents with nutritional issues, unsafe food temperatures during meal service, and incomplete medical records including discharge summaries and CNA documentation.
Complaint Details
Complaint NJ#167957 related to food temperatures and complaint NJ#162723, 162811 related to medical records and discharge summaries.
Findings
The facility failed to ensure timely physician visits for residents with weight loss, maintain safe and appetizing food temperatures during meal delivery, and keep complete and accessible medical records including physician discharge summaries and CNA documentation of resident care.
Deficiencies (3)
Failed to ensure physician conducted face-to-face visits at least every sixty days and wrote progress notes for a resident with weight loss.
Failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures; hot foods served below recommended temperatures.
Failed to maintain complete and readily accessible medical records including missing physician discharge summaries and CNA documentation of ADL care.
Report Facts
Resident count reviewed for nutrition: 10
Significant weight loss percentage: 5.2
Food temperature measurements: 121.9
Food temperature measurements: 125.5
Food temperature measurements: 119.2
Food temperature measurements: 55.2
Food temperature measurements: 121.8
Food temperature measurements: 55
Residents reviewed for medical records: 38
Resident cognitive score: 3
Resident cognitive score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | Discussed concerns about physician visits and food temperatures. | |
| Director of Nursing | Discussed concerns about physician visits, food temperatures, and medical record deficiencies. | |
| Food Service Director | Interviewed regarding food temperatures and meal delivery. | |
| Licensed Practical Nurse | Provided information about CNA documentation practices. | |
| Certified Nursing Assistant #1 | Interviewed about staffing and meal delivery delays. | |
| Director of Nursing | Interviewed regarding missing physician discharge summary. |
Inspection Report
Routine
Census: 18
Deficiencies: 24
Date: Feb 6, 2024
Visit Reason
Routine inspection conducted to evaluate compliance with resident rights, care, environment, staffing, infection control, medication administration, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to serve lunch trays timely to all residents at a table, failure to offer advance directives, unsafe and unclean environment, failure to verify licensed staff credentials prior to hire, failure to timely report injury of unknown origin, incomplete fall investigations, failure to provide timely notification to ombudsman for hospital transfers, inaccurate MDS coding, incomplete care plans, medication administration errors, inadequate wound care and hand hygiene, failure to monitor urinary output for residents with catheters, failure to provide appropriate respiratory care, failure to maintain kitchen sanitation, failure to dispose garbage properly, failure to safeguard resident information, failure to implement antibiotic stewardship program, failure to provide flu and pneumonia vaccinations properly, failure to observe nurse aide competency and training requirements, failure to post nurse staffing information, and failure to maintain infection prevention and control program.
Deficiencies (24)
Failure to serve all residents seated at a table their lunch trays in a timely manner.
Failure to ensure residents or their representatives were offered the opportunity to formulate an Advance Directive.
Failure to provide residents with a safe, clean, comfortable and homelike environment.
Failure to ensure licensed staff credentials were verified upon hire.
Failure to timely report injury of unknown origin to the state agency.
Failure to complete a thorough investigation of a fall incident.
Failure to provide timely notification of emergency transfer to the Long-Term Care Ombudsman.
Failure to accurately code the Minimum Data Set (MDS) assessments.
Failure to develop and implement comprehensive care plans to meet residents' needs.
Failure to ensure medication was administered according to manufacturer's cautionary specifications and professional standards.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failure to monitor urinary output for residents with indwelling catheters.
Failure to provide safe and appropriate respiratory care according to physician's order and standards of practice.
Failure to ensure nurse aides who have worked more than 4 months are trained and competent and failure to have a delineated policy for hiring and staffing non-certified nurse aides.
Failure to provide annual performance reviews for Certified Nursing Aides.
Failure to post 24-hour nurse staffing report in a prominent and accessible location.
Failure to provide pharmaceutical services in accordance with professional standards including labeling medications with expiration dates, removing expired and discontinued medications from active inventory.
Failure to ensure food and drink are palatable, attractive, and served at safe and appetizing temperatures.
Failure to dispose of garbage and refuse properly, resulting in unsanitary conditions around garbage compactor and dumpster.
Failure to safeguard resident-identifiable information and maintain complete medical records.
Failure to have the Infection Preventionist present at quarterly Quality Assurance Performance Improvement meetings.
Failure to maintain infection control standards including COVID-19 testing, PPE storage, and hand hygiene practices.
Failure to implement an antibiotic stewardship program with routine feedback and tracking measures.
Failure to develop and implement policies and procedures for flu and pneumonia vaccinations including documentation of consent or refusal.
Report Facts
Residents present during lunch: 18
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Nurse aides: 5
Days: 2
Medication cart shifts: 10
Residents: 1
COVID-19 positive residents: 3
COVID-19 positive staff: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in delayed lunch tray service and infection control hand hygiene finding |
| CNA #2 | Certified Nursing Assistant | Named in delayed lunch tray service and infection control hand hygiene finding |
| CNA #3 | Certified Nursing Assistant | Named in infection control hand hygiene finding |
| LPN #1 | Licensed Practical Nurse | Named in delayed lunch tray service, medication administration, infection control hand hygiene, and respiratory care findings |
| LPN #2 | Licensed Practical Nurse | Named in delayed lunch tray service, infection control hand hygiene, and respiratory care findings |
| LPN #3 | Licensed Practical Nurse | Named in delayed lunch tray service and respiratory care findings |
| RN #1 | Registered Nurse | Named in medication administration and infection control findings |
| RN #2 | Registered Nurse | Named in medication administration and respiratory care findings |
| Director of Nursing | Director of Nursing | Named in multiple findings including infection control, antibiotic stewardship, and care plan oversight |
| Licensed Nursing Home Administrator | Administrator | Named in multiple findings including infection control, antibiotic stewardship, and care plan oversight |
| Human Resources Manager | Human Resources Manager | Named in nurse aide hiring and credential verification finding |
| Director of Activities | Director of Activities | Named in nurse aide hiring and credential verification finding |
| Wound Care Registered Nurse | Wound Care Registered Nurse | Named in wound care and hand hygiene finding |
Inspection Report
Complaint Investigation
Census: 261
Deficiencies: 2
Date: Mar 21, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to multiple complaints regarding resident-to-resident physical abuse incidents.
Complaint Details
The complaint investigation involved multiple complaint numbers (NJ00158248, NJ0059988, NJ00160177, NJ00160829, NJ00161593) and focused on incidents of resident-to-resident physical abuse involving Residents 4 and 17, as well as Residents 20 and 21. The facility failed to prevent harm and failed to report the incidents timely to the State Survey Agency.
Findings
The facility was found not in substantial compliance with requirements related to freedom from abuse and neglect, specifically failing to prevent resident-to-resident physical abuse involving two residents who were injured by a metal object. Additionally, the facility failed to timely report alleged violations of abuse to the State Survey Agency as required.
Deficiencies (2)
Failure to ensure two residents were free from resident-to-resident physical abuse resulting in harm from being hit with a metal object.
Failure to immediately report alleged violations involving abuse to the New Jersey Department of Health within required timelines.
Report Facts
Survey Census: 261
Sample Size: 21
Reporting delay: 15.5
Reporting delay: 17.75
Days delay: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 5 | LPN | Wrote progress notes documenting the resident-to-resident altercation and injuries |
| Director of Nursing | DON | Provided statements regarding the incident, reporting procedures, and facility policies |
| Assistant Director of Nursing | ADON | Reviewed incident notes and provided information about reporting timelines |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 21, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding resident-to-resident physical abuse incidents involving two residents (R4 and R17) and a failure to timely report suspected abuse and update abuse reporting policies.
Complaint Details
The complaint investigation was related to Intake NJ 00160829 involving resident-to-resident physical abuse incidents between residents R4 and R17, and between residents R20 and R21. The investigation found substantiated abuse with actual harm to residents and failures in timely reporting and policy updates.
Findings
The facility failed to ensure residents were free from physical abuse, resulting in actual harm with multiple injuries sustained by residents R4 and R17. Additionally, the facility failed to timely report two incidents of resident-to-resident physical altercations to the state agency and did not update its abuse reporting and response policy to meet regulatory requirements.
Deficiencies (3)
Failed to protect residents from resident-to-resident physical abuse resulting in actual harm with injuries including sutures, lacerations, bruises, facial trauma, and a human bite mark.
Failed to timely report suspected abuse incidents to the New Jersey Department of Health within required timeframes.
Failed to update abuse reporting and response policy to ensure timely reporting of abuse, neglect, exploitation, or mistreatment.
Report Facts
Time delay in reporting incident between R4 and R17: 15.5
Time delay in reporting incident between R20 and R21: 17.75
Time delay in faxing investigation report for incident between R20 and R21: 15
BIMS score for R4: 15
BIMS score for R17: 15
Number of sutures/staples for R4: 9
Antibiotic treatment duration for R17: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Wrote progress notes documenting the resident-to-resident altercation and injuries |
| Director of Nursing | Director of Nursing | Completed Reportable Event Record, interviewed regarding incident and reporting procedures |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding reporting timelines for incidents |
Inspection Report
Complaint Investigation
Census: 268
Deficiencies: 3
Date: Aug 2, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health due to a COVID-19 outbreak and concerns about compliance with infection control and vaccination requirements.
Complaint Details
The visit was complaint-related due to concerns about COVID-19 testing frequency and vaccination compliance during a COVID-19 outbreak at the facility. The facility was found non-compliant with infection control and vaccination regulations.
Findings
The facility failed to conduct COVID-19 testing of unvaccinated staff at the frequency required by CDC guidance during a COVID-19 outbreak and failed to ensure staff were up-to-date on COVID-19 vaccinations, including boosters, as required by New Jersey Executive Order No. 290. The facility also lacked a system to track temporary delays in vaccination and did not fully implement contingency plans for unvaccinated staff.
Deficiencies (3)
Failed to conduct COVID-19 testing of unvaccinated staff at required frequency during outbreak.
Failed to ensure staff were up-to-date on COVID-19 vaccinations and boosters, and lacked tracking for temporary delays or exemptions.
Failed to comply with New Jersey Administrative Code 8:39-5.1(a) regarding mandatory access to care and vaccination requirements.
Report Facts
Census: 268
Staff tested once a week: 6
Staff eligible for booster: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding COVID-19 testing and vaccination compliance |
| Director of Nursing | DON | Interviewed regarding COVID-19 testing and vaccination compliance |
| Infection Preventionist Nurse | IPN | Interviewed regarding COVID-19 testing and vaccination compliance |
| Human Resources Staff Member | HRSM | Provided vaccination records and staff lists |
| Housekeeper #1 | Interviewed about COVID-19 testing frequency | |
| Certified Nursing Aide #1 | CNA | Interviewed about COVID-19 testing frequency |
| Unit Clerk | UC | Interviewed about COVID-19 testing frequency and vaccination status |
| Food Service Employee #1 | FSE | Interviewed about COVID-19 testing frequency |
| Food Service Director | FSD | Interviewed about COVID-19 testing procedures |
| Housekeeper #2 | Interviewed about COVID-19 testing frequency |
Inspection Report
Complaint Investigation
Census: 242
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ151277, NJ149589, and NJ146773.
Complaint Details
The complaint survey found the facility in compliance with all applicable regulations.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities and with infection control regulations related to COVID-19.
Report Facts
Sample Size: 8
Inspection Report
Follow-Up
Census: 232
Deficiencies: 1
Date: Sep 28, 2021
Visit Reason
The inspection was conducted to assess compliance with New Jersey state staffing requirements for nursing homes, specifically regarding minimum direct care staff-to-resident ratios.
Findings
The facility was found not in compliance with the minimum direct care staff-to-resident ratios mandated by New Jersey state law, with staffing levels below required minimums on multiple shifts and dates. The facility documented ongoing recruitment and retention efforts to address staffing shortages. A follow-up revisit report dated 11/01/2021 confirmed that the deficiency was corrected by 10/28/2021.
Deficiencies (1)
Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Report Facts
Census: 232
Residents per CNA: 16.5
Residents per CNA: 12.8
Residents per CNA: 19.3
Residents per CNA: 13.5
Residents per CNA: 14.4
Residents per CNA: 23.1
Residents per CNA: 14.4
Residents per CNA: 16.5
Residents per CNA: 25.6
Residents per CNA: 10.9
Residents per CNA: 12.7
Residents per CNA: 19
Residents per CNA: 13.4
Residents per CNA: 13.4
Residents per CNA: 17.5
Residents per CNA: 12.1
Residents per CNA: 12.1
Residents per CNA: 16.4
Residents per CNA: 12.2
Residents per CNA: 16.5
Residents per CNA: 17.8
Residents per CNA: 14.5
Residents per CNA: 15.4
Residents per CNA: 19.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding minimum staffing requirements for the state of New Jersey |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding minimum staffing requirements and staffing efforts |
| 4 West CNA | Certified Nurse Aide | Interviewed about resident assignments and workload |
| Licensed Practical Nurse/Unit Manager | LPN/Unit Manager | Interviewed about staffing and census on the fourth floor |
| Registered Nurse/Unit Manager | RN/Unit Manager | Interviewed about staffing and census on the fifth floor |
| 3West Licensed Practical Nurse | LPN | Interviewed about staffing and resident assignments on 3West unit |
Inspection Report
Routine
Census: 232
Deficiencies: 8
Date: Sep 28, 2021
Visit Reason
The survey was conducted as a routine recertification inspection to assess compliance with regulatory requirements and investigate complaints related to staffing and care.
Findings
The facility was found deficient in multiple areas including failure to ensure pre-admission screening and resident review (PASRR) assessments prior to admission for residents transferred to a behavioral unit, failure to provide necessary rehabilitative services and equipment to maintain residents' highest functional level, failure to obtain and address significant weight loss in a resident, failure to post oxygen cautionary signage and document oxygen administration properly, inadequate staffing levels on multiple units, failure to serve food at appropriate temperatures, improper food handling and storage practices in the kitchen, and failure to follow infection control protocols during wound care.
Deficiencies (8)
Failure to ensure residents admitted to a behavioral unit received PASRR assessments prior to admission.
Failure to provide rehabilitative services and equipment to maintain resident's highest functional level, including delayed provision of bariatric wheelchair and holding off restorative nursing program.
Failure to obtain resident re-weights per facility policy and failure to address significant unplanned weight loss of 15.9%.
Failure to post oxygen cautionary signage and accurately document oxygen administration per physician order.
Failure to provide sufficient nursing staff to meet resident needs and comply with minimum staffing requirements.
Failure to serve hot and cold foods at acceptable temperatures during meal service.
Failure to properly handle and store potentially hazardous foods, maintain kitchen equipment and areas in a clean and sanitary manner, and maintain adequate infection control practices during meal service.
Failure to follow infection control protocol to prevent spread of infection during wound care treatment observation.
Report Facts
Residents transferred to behavioral unit without PASRR: 25
Resident weight loss percentage: 15.9
Facility census: 232
CNA to resident ratio: 16.5
Food temperatures: 138
Food temperatures: 124
Food temperatures: 126
Food temperatures: 110
Food temperatures: 118
Food temperatures: 56
Sanitizer concentration: 50
Sanitizer concentration: 150
CNA to resident ratio: 12
CNA to resident ratio: 9.6
CNA to resident ratio: 14.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RD #1 | Registered Dietician | Reviewed resident weight loss and confirmed failure to obtain re-weight. |
| RD #2 | Registered Dietician | Responsible for nutrition assessments and weight monitoring; failed to address significant weight loss. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staffing, weight monitoring, and wound care competency. |
| FSD | Food Service Director | Interviewed regarding food temperatures, food storage, and kitchen sanitation. |
| AFSD | Assistant Food Service Director | Observed meal service and food storage practices. |
| LPN/UM | Licensed Practical Nurse/Unit Manager | Interviewed regarding oxygen administration and staffing. |
| LPN | Licensed Practical Nurse | Observed performing wound care and interviewed about infection control practices. |
| CNA | Certified Nursing Assistant | Interviewed regarding resident care and oxygen use. |
Inspection Report
Complaint Investigation
Census: 237
Deficiencies: 4
Date: Jul 2, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ144098, NJ143056, and NJ142410 regarding infection prevention and control practices during the COVID-19 pandemic.
Complaint Details
The complaint investigation involved multiple complaints (NJ144098, NJ143056, NJ142410) focused on infection prevention and control failures during the COVID-19 pandemic. The facility was found non-compliant with 42 CFR Part 483, Subpart B, based on these complaints.
Findings
The facility failed to implement an effective infection prevention and control program, including failure to ensure social distancing between vaccinated and unvaccinated residents, improper mask use by staff, failure to use appropriate PPE when caring for a person under investigation for COVID-19, and staff exiting resident rooms with gloves on. These deficiencies had the potential to affect all residents during the COVID-19 pandemic.
Deficiencies (4)
Failure to ensure social distancing between vaccinated and unvaccinated residents in the dining room.
Staff failed to wear masks properly over their nostrils when providing direct care.
Direct care staff failed to use appropriate PPE when providing care to a resident who was a person under investigation for COVID-19.
Staff exited residents' rooms with gloves still on, risking contamination of common areas.
Report Facts
Residents present during group activity: 12
Unvaccinated residents present: 2
Unvaccinated staff present: 1
Census: 237
Sample Size: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Failed to wear appropriate PPE when providing care to Resident #5, a person under investigation for COVID-19. |
| LPN #1 | Licensed Practical Nurse | Observed passing medications without proper mask use; acknowledged mask frequently slipped below nose. |
| LPN #2 | Licensed Practical Nurse | Observed passing medications without proper mask use. |
| CNA #4 | Certified Nurse Aide | Observed providing direct care without proper mask use. |
| CNA #2 | Certified Nurse Aide | Walked around the unit with gloves on, failing to remove gloves after direct care. |
| CNA #3 | Certified Nurse Aide | Walked around the unit with gloves on, failing to remove gloves after direct care. |
| Assistant Activities Director (AAD) | Activities Assistant Director | Coordinated group activities without enforcing mask use or social distancing; was unvaccinated and wore mask below jaw. |
| Infection Control Preventionist (ICP) | Infection Control Preventionist | Provided infection control training and emphasized importance of PPE and social distancing. |
| Director of Nursing (DON) | Director of Nursing | Oversaw infection control compliance and acknowledged staff complacency after lifting of Immediate Jeopardy. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 16, 2021
Visit Reason
The inspection was conducted as a COVID-19 Federal Infection Control Survey triggered by a complaint and focused on infection prevention and control practices related to COVID-19 exposure and outbreak management.
Complaint Details
The visit was complaint-related, triggered by concerns about COVID-19 infection control practices, including failure to identify exposed residents and failure to implement appropriate precautions and outbreak response.
Findings
The facility was found in Immediate Jeopardy on 04/16/21 for failing to identify residents exposed to COVID-19 as persons under investigation, failing to place exposed residents on transmission-based precautions, not properly implementing the outbreak response plan, and not employing a full-time infection preventionist with appropriate training. The facility failed to ensure staff donned appropriate PPE for residents on transmission-based precautions. The Immediate Jeopardy was removed on 04/20/21 after an acceptable removal plan was implemented and verified on 04/21/21.
Deficiencies (3)
Failure to identify residents exposed to COVID-19 as persons under investigation and failure to place them on transmission-based precautions.
Failure to employ a full-time infection preventionist with appropriate education and training.
Failure to ensure staff appropriately don personal protective equipment (PPE) for residents on transmission-based precautions.
Report Facts
Residents reviewed: 17
Residents exposed to COVID-19: 14
Date of survey: Apr 16, 2021
Date of removal plan acceptance: Apr 20, 2021
Date of removal verification survey: Apr 21, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Tested positive for COVID-19 and provided direct care to exposed residents. |
| IRN/IP | Interim Registered Nurse/Infection Preventionist | Interviewed regarding infection control practices and training; not full-time Infection Preventionist. |
| DON | Director of Nursing | Interviewed regarding PPE requirements and infection control education. |
| LPN/ADON | Licensed Practical Nurse/Assistant Director of Nursing | Interviewed regarding PPE requirements and resident care assignments. |
| OT | Occupational Therapist | Observed not wearing full PPE when entering a resident's room on transmission-based precautions. |
| LPN/UM | Licensed Practical Nurse/Unit Manager | Interviewed about PPE requirements and infection control practices. |
| HK #1 | Housekeeper | Observed not wearing full PPE when cleaning resident rooms on transmission-based precautions. |
| HK #2 | Housekeeper | Interviewed about PPE use when cleaning resident rooms. |
| HK #3 | Housekeeper | Observed not wearing full PPE when cleaning resident room on transmission-based precautions. |
| LPN #1 | Licensed Practical Nurse | Interviewed about PPE requirements and resident care. |
| LPN #2 | Licensed Practical Nurse | Interviewed about PPE requirements and resident care. |
| OT/RD | Occupational Therapist/Rehab Director | Provided in-service education on PPE requirements for residents on transmission-based precautions. |
Inspection Report
Routine
Census: 197
Deficiencies: 0
Date: Feb 10, 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: 17
Inspection Report
Complaint Investigation
Census: 207
Deficiencies: 0
Date: Dec 21, 2020
Visit Reason
The inspection was conducted in response to complaints NJ00134528 and NJ00130701 to assess compliance with regulatory requirements for long term care facilities.
Complaint Details
Complaint numbers NJ00134528 and NJ00130701 were investigated and found to be compliant with no deficiencies cited.
Findings
The facility was found to be in compliance with the requirements of CFR Part 483, Subpart B, based on this complaint survey.
Report Facts
Sample Size: 6
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