Inspection Reports for Peace Care St. Joseph’s
537 Pavonia Ave #1803, Jersey City, NJ 07306, United States, NJ, 07306
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Census: 124
Capacity: 128
Deficiencies: 15
Nov 7, 2024
Visit Reason
The survey was conducted as a Standard Survey from 10/31 to 11/7/2024 to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities, including complaint investigations.
Findings
Deficiencies were cited related to care of dependent residents, respiratory care and tracheostomy, medication administration, staffing, pharmacy services, infection prevention and control, influenza and pneumococcal immunizations, life safety code compliance including egress doors, emergency lighting, sprinkler systems, HVAC, elevators, and electrical systems. Corrective actions were planned or taken for all cited deficiencies.
Severity Breakdown
SS=F: 10
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to provide necessary services to dependent residents unable to carry out activities of daily living. | — |
| Respiratory care including tracheostomy care and suctioning not provided consistent with professional standards. | — |
| Medication errors including failure to identify other residents affected and improper handling of controlled substances. | — |
| Insufficient nursing staff to meet minimum direct care staff-to-resident ratios. | — |
| Pharmacy services failed to provide routine and emergency drugs and maintain accurate records. | — |
| Infection prevention and control program deficiencies including failure to maintain hand hygiene and proper isolation procedures. | — |
| Failure to ensure residents received influenza and pneumococcal immunizations as required. | — |
| Life Safety Code deficiencies including improper egress door locking mechanisms and signage. | SS=F |
| Emergency lighting failed to provide required duration of illumination. | SS=F |
| Sprinkler system installation and maintenance deficiencies. | SS=F |
| Portable fire extinguishers not properly maintained or replaced. | SS=F |
| HVAC system air filters clogged and dirty. | SS=F |
| Elevators failed to ensure safe operation and compliance with inspection requirements. | SS=F |
| Fire doors and door assemblies failed inspection and testing requirements. | SS=F |
| Electrical systems failed annual inspection and testing requirements. | SS=F |
Report Facts
Census: 124
Total Capacity: 128
Survey Dates: 8
Completion Dates: 11
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 2
Sep 20, 2024
Visit Reason
The inspection was conducted based on a complaint visit (Complaint # NJ00177077) to assess compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to ensure medication orders for a resident admitted from the hospital were completely and accurately relayed, with missing discontinued medication documentation. Additionally, the facility failed to maintain complete and accurate resident medical records, including missing pages of hospital discharge medication instructions.
Complaint Details
Complaint # NJ00177077. The facility was found not in substantial compliance based on this complaint visit related to medication order inaccuracies and incomplete medical records.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure medication orders for a resident admitted from the hospital were completely and accurately relayed, including missing discontinued medications documentation. | SS=D |
| Failure to maintain accurate and complete resident medical records, including missing pages of hospital discharge medication instructions. | SS=D |
Report Facts
Census: 122
Sample size: 3
Deficiency correction completion date: Sep 23, 2024
Revisit date: Oct 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Documented Resident #1's progress notes regarding medication administration and refusal. |
| RN #2 | Registered Nurse | Documented Resident #1's progress notes regarding medication refusal and communication with physician. |
| RN #3 | Registered Nurse | Interviewed by surveyor; stated responsibility for following up with physician on medication list upon admission. |
| RN #4 | House Supervisor Registered Nurse | Interviewed by surveyor; responsible for admission medication verification and acknowledged missing medication documentation. |
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 12
Aug 22, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Findings
Deficiencies were cited related to accuracy of assessments, comprehensive care plans, treatment and services to prevent/heal pressure ulcers, dialysis care, pharmacy services, food procurement and sanitation, infection prevention and control, quality assessment and assurance committee attendance, and life safety code violations including emergency lighting and elevator maintenance.
Complaint Details
Complaint #s NJ00157451, NJ00163644, NJ00161813, NJ00165308, NJ00165172. Complaint investigations were completed during this survey.
Severity Breakdown
SS=D: 5
SS=G: 1
SS=E: 2
SS=F: 4
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility failed to accurately complete the Minimum Data Set (MDS) for 5 of 24 residents reviewed. | SS=D |
| Facility failed to develop a comprehensive, person-centered care plan addressing residents' specific needs for 2 of 23 residents reviewed. | SS=D |
| Facility failed to provide effective care and services to promote healing for pressure ulcers for 1 of 2 residents reviewed. | SS=G |
| Facility failed to assess for complications upon return from dialysis and consistently monitor fluid restrictions for 2 of 2 residents reviewed. | SS=E |
| Facility failed to accurately document medication administration and clarify duplicate physician's orders for 5 of 9 residents reviewed. | SS=D |
| Facility failed to sanitize and air dry steam table pans properly to prevent microbial growth. | SS=D |
| Facility failed to assure required staff attended quarterly Quality Assurance meetings for 2 of 2 meetings reviewed. | SS=E |
| Facility failed to adhere to infection control practices including proper glove use and hand hygiene during care and food preparation. | SS=D |
| Facility failed to provide battery backup emergency lighting independent of building electrical system for fire pump transfer switch. | SS=F |
| Facility failed to ensure documented evidence of annual firefighter's service testing and failed to ensure elevators were inspected annually. | SS=F |
| Facility failed to ensure fire doors were inspected annually and failed to label fire doors with fire rating as required. | SS=F |
| Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. | — |
Report Facts
Census: 111
Sample Size: 26
Deficiency Count: 5
Deficiency Count: 2
Deficiency Count: 1
Deficiency Count: 2
Deficiency Count: 5
Deficiency Count: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Interviewed regarding Resident #48 and medication administration | |
| Certified Nursing Assistant #1 | Observed and interviewed regarding glove use and hand hygiene | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies and corrective actions |
| Maintenance Director | MD | Interviewed regarding emergency lighting and elevator maintenance |
| Administrator | ADMIN | Interviewed regarding multiple deficiencies and corrective actions |
| MDS Coordinator | Interviewed regarding MDS assessment inaccuracies | |
| Consultant Pharmacist | CP | Interviewed regarding medication administration and pharmacy services |
| Wound Consultant | Interviewed regarding wound care and treatment orders |
Inspection Report
Abbreviated Survey
Census: 102
Deficiencies: 0
Feb 6, 2023
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 had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
May 5, 2022
Visit Reason
The inspection visit was conducted as a complaint investigation to assess compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The facility was found to be in substantial compliance with the regulatory requirements based on this complaint visit.
Complaint Details
The visit was complaint-related and the facility was found to be in substantial compliance.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Feb 16, 2022
Visit Reason
The inspection was conducted as a complaint survey (Complaint #: NJ149186) to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the applicable requirements based on this complaint survey. A COVID-19 Focused Infection Control Survey also found the facility in compliance with infection control regulations and recommended CDC practices.
Complaint Details
Complaint #: NJ149186. The facility was found to be in compliance with all requirements based on this complaint survey.
Report Facts
Sample Size: 15
Inspection Report
Follow-Up
Census: 89
Deficiencies: 1
Jan 26, 2022
Visit Reason
The visit was conducted to assess compliance with mandatory staffing requirements and to follow up on previously identified deficiencies related to direct care staff-to-resident ratios at Peace Care St Joseph's.
Findings
The facility was found deficient in maintaining the required minimum direct care staff-to-resident ratios on several day shifts, specifically lacking sufficient certified nurse aides (CNAs). The facility has implemented multiple corrective actions including staffing agency contracts, wage increases, incentives, and recruitment efforts to address the deficiencies.
Deficiencies (1)
| Description |
|---|
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey state law. |
Report Facts
Deficiencies cited: 3
Resident census: 94
Resident census: 89
Certified Nurse Aides (CNAs) present: 10
Certified Nurse Aides (CNAs) present: 11
Certified Nurse Aides (CNAs) required: 12
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 0
May 28, 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 not cited for this survey, indicating compliance with regulatory requirements.
Report Facts
Sample records reviewed: 21
Inspection Report
Life Safety
Deficiencies: 0
May 25, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations to assess compliance with Medicare/Medicaid participation requirements related to life safety from fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Findings
Peace Care St Joseph's was found to be in compliance with the Life Safety Code requirements. The facility is a four-story building with multi-phase construction and is divided into 20 smoke zones.
Report Facts
Smoke zones: 20
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Dec 1, 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 related to COVID-19.
Findings
The facility failed to follow appropriate infection control practices, specifically in implementing transmission-based precautions for residents exposed to a COVID-19 positive staff member and in performing proper hand hygiene. Several staff members did not consistently use full personal protective equipment (PPE) or perform hand hygiene as required, and residents exposed to COVID-19 positive staff were not always placed on transmission-based precautions.
Complaint Details
The visit was complaint-related due to concerns about infection control practices related to COVID-19 exposure and transmission within the facility. The complaint was substantiated based on observations, interviews, and record reviews.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement designated transmission-based precautions for residents exposed to a COVID-19 positive direct care staff member. | SS=E |
| Failure to perform hand hygiene for the appropriate amount of time. | SS=E |
Report Facts
Census: 86
Sample size: 9
Quarantine duration: 14
Observation period: 14
Monitoring period: 3
Monitoring period quarterly: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided inservice education and described infection control practices and deficiencies. |
| RN Infection Preventionist | RN Infection Preventionist | Provided inservice education, monitored staff performance, and described infection control practices. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Participated in entrance conference and survey discussions. |
| Chief Corporate Officer | Chief Corporate Officer | Participated in entrance conference and survey discussions. |
| RN Unit Manager | Registered Nurse Unit Manager | Described PPE use and staff assignments on the fourth floor. |
| Certified Nursing Aide #1 | Certified Nursing Aide | Tested positive for COVID-19 on 11/18/2020. |
| Certified Nursing Aide #2 | Certified Nursing Aide | Tested positive for COVID-19 on 11/25/2020 and was quarantined. |
| Certified Nursing Aide #3 | Certified Nursing Aide | Observed and interviewed regarding PPE use and hand hygiene. |
| Certified Nursing Aide #4 | Certified Nursing Aide | Observed and interviewed regarding PPE use and hand hygiene. |
| Certified Nursing Aide #5 | Certified Nursing Aide | Observed donning full PPE and described PPE practices. |
| Certified Nursing Aide #6 | Certified Nursing Aide | Observed handling meal trays and PPE use. |
| Environmental Services Staff | Housekeeper | Observed PPE use and described cleaning practices. |
| Registered Nurse | Registered Nurse | Provided resident care and described PPE and monitoring practices. |
| Director of Environmental Services | Director of Environmental Services | Described housekeeping PPE practices and assignments. |
| Assistant Director of Nursing/Infection Preventionist | Assistant Director of Nursing/Infection Preventionist | Provided infection control guidance and education. |
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