Inspection Reports for New Vista Nursing and Rehabilitation Center
NJ, 07104
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Notice
Deficiencies: 0
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
Complaint Investigation
Census: 267
Deficiencies: 1
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.
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.
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.
Deficiencies (1)
| Description |
|---|
| 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
Feb 6, 2024
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 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.
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.
Severity Breakdown
SS=E: 18
SS=D: 14
SS=C: 3
SS=F: 5
: 1
Deficiencies (41)
| Description | Severity |
|---|---|
| Facility failed to serve all residents seated at a table their lunch trays in a timely manner. | SS=D |
| Facility failed to ensure residents or representatives were offered the opportunity to formulate an advance directive. | SS=D |
| Facility failed to provide a safe, comfortable, clean, and homelike environment; observed dirty fan, broken nightstand, and commode in dining area. | SS=E |
| Facility failed to verify licensed staff credentials upon hire prior to date of hire for five licensed staff. | SS=E |
| Facility failed to report an alleged violation involving injury of unknown source to the state agency within required timeframe. | SS=D |
| Facility failed to complete a thorough investigation of an injury of unknown source for one resident. | SS=D |
| Facility failed to provide a care plan addressing anticoagulant use, pain, smoking, and palliative care for four residents. | SS=D |
| 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. | SS=D |
| Facility failed to notify the Office of the State Long-Term Care Ombudsman of resident hospital transfer for one resident. | SS=C |
| Facility failed to maintain complete medical records including discharge summaries for two residents. | SS=D |
| Facility failed to ensure that expired medications were removed from active inventory and medication labeling was accurate. | SS=D |
| Facility failed to maintain safe food handling and sanitation practices in kitchen including unlabeled food, unwashed lettuce, dirty equipment, and improper storage. | SS=F |
| Facility failed to ensure hand hygiene was performed correctly by staff during wound care and medication administration. | SS=E |
| Facility failed to ensure COVID-19 testing was conducted according to CDC guidance during outbreak for residents and staff. | SS=E |
| Facility failed to ensure physician face-to-face visits were conducted at least every 60 days and documented for one resident. | SS=D |
| Facility failed to develop and implement comprehensive care plans addressing residents' medical, physical, mental, and psychosocial needs for four residents. | SS=D |
| Facility failed to ensure medication administration and care were provided according to professional standards for two residents. | SS=D |
| Facility failed to ensure patency monitoring and documentation of urinary catheters for two residents. | SS=D |
| Facility failed to ensure oxygen therapy was administered according to physician orders and professional standards for three residents. | SS=E |
| Facility failed to provide written notification of hospital transfer to the Office of the State Long-Term Care Ombudsman for one resident. | SS=C |
| Facility failed to ensure accurate MDS coding for oxygen therapy and influenza vaccination for three residents. | SS=D |
| Facility failed to ensure residents' influenza and pneumococcal immunization status was documented including consent or refusal for four residents. | SS=E |
| Facility failed to ensure annual performance reviews were completed for five Certified Nursing Aides. | SS=E |
| Facility failed to ensure non-certified Nurse Aides did not work beyond 120 days without enrollment in approved training program. | SS=D |
| Facility failed to ensure criminal background checks were completed prior to date of hire for four newly hired employees. | SS=D |
| Facility failed to ensure new employees received health history and physical examination within required timeframe for six employees. | SS=D |
| Facility failed to ensure hand hygiene was performed correctly by staff and surgical masks were not stored properly during wound care and medication administration. | SS=E |
| Facility failed to ensure expired and discontinued medications were removed from active inventory and medication labeling was accurate. | SS=D |
| Facility failed to ensure food was served at safe and appetizing temperatures during meal service. | SS=D |
| Facility failed to ensure proper kitchen sanitation, food storage, and food handling practices to prevent foodborne illness. | SS=F |
| Facility failed to ensure medical records were complete and readily accessible including documentation of ADL care and discharge summaries for two residents. | SS=D |
| Facility failed to ensure antibiotic stewardship program was implemented with appropriate tracking, feedback, and reporting. | SS=C |
| Facility failed to ensure influenza and pneumococcal immunizations were offered, administered, or declined with proper documentation for multiple residents. | SS=E |
| Facility failed to ensure minimum direct care staff to resident ratios were met for Certified Nursing Aides and total staff on multiple shifts. | SS=D |
| Facility failed to ensure non-certified Nurse Aides were enrolled in approved training programs within required timeframes. | SS=D |
| Facility failed to ensure new employees received physical examinations or nursing assessments within required timeframes. | SS=D |
| Facility failed to ensure smoke detectors were installed at least 36 inches away from air diffusers in corridors. | SS=E |
| Facility failed to complete smoke detection sensitivity testing for all smoke detectors every two years. | SS=F |
| Facility failed to ensure linen chute door was self-closing and latched properly. | SS=E |
| Facility failed to ensure smoking area contained a metal self-closing container for cigarette disposal and was kept clean. | SS=E |
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
Census: 261
Deficiencies: 2
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.
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.
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.
Severity Breakdown
SS=G: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure two residents were free from resident-to-resident physical abuse resulting in harm from being hit with a metal object. | SS=G |
| Failure to immediately report alleged violations involving abuse to the New Jersey Department of Health within required timelines. | SS=D |
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
Census: 268
Deficiencies: 3
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.
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.
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.
Severity Breakdown
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to conduct COVID-19 testing of unvaccinated staff at required frequency during outbreak. | SS=E |
| Failed to ensure staff were up-to-date on COVID-19 vaccinations and boosters, and lacked tracking for temporary delays or exemptions. | SS=E |
| 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
Feb 23, 2022
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ151277, NJ149589, and NJ146773.
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.
Complaint Details
The complaint survey found the facility in compliance with all applicable regulations.
Report Facts
Sample Size: 8
Inspection Report
Follow-Up
Census: 232
Deficiencies: 1
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)
| Description |
|---|
| 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
Complaint Investigation
Census: 237
Deficiencies: 4
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.
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.
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.
Severity Breakdown
SS=F: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure social distancing between vaccinated and unvaccinated residents in the dining room. | SS=F |
| Staff failed to wear masks properly over their nostrils when providing direct care. | SS=F |
| Direct care staff failed to use appropriate PPE when providing care to a resident who was a person under investigation for COVID-19. | SS=F |
| Staff exited residents' rooms with gloves still on, risking contamination of common areas. | SS=F |
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
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.
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.
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.
Severity Breakdown
Immediate Jeopardy: 2
Pattern with no actual harm but potential for more than minimal harm: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to identify residents exposed to COVID-19 as persons under investigation and failure to place them on transmission-based precautions. | Immediate Jeopardy |
| Failure to employ a full-time infection preventionist with appropriate education and training. | Immediate Jeopardy |
| Failure to ensure staff appropriately don personal protective equipment (PPE) for residents on transmission-based precautions. | Pattern with no actual harm but potential for more than minimal harm |
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
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
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.
Findings
The facility was found to be in compliance with the requirements of CFR Part 483, Subpart B, based on this complaint survey.
Complaint Details
Complaint numbers NJ00134528 and NJ00130701 were investigated and found to be compliant with no deficiencies cited.
Report Facts
Sample Size: 6
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