Inspection Reports for Preferred Care at Absecon

NJ, 08201

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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/year

Deficiencies per year

12 9 6 3 0
2020
2021
2022
2023
2024
2025

Census

Latest occupancy rate 94% occupied

Based on a December 2024 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Census over time

80 100 120 140 160 180 Dec 2020 Jan 2021 Aug 2021 Jul 2022 Sep 2023 Dec 2024

Notice

Deficiencies: 0 Date: 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 regarding their health information, and the legal duties of NJDHSS to protect privacy.

Report Facts
Effective date: 2011

Employees mentioned
NameTitleContext
Devon L. GrafDirector, Office of Legal and Regulatory ComplianceListed as NJDHSS Privacy Officer contact for questions about the notice

Inspection Report

Routine
Census: 152 Capacity: 162 Deficiencies: 10 Date: Dec 23, 2024

Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey included complaint investigations for complaint numbers NJ 169201, 169245, and 170494.

Complaint Details
The survey included complaint investigations for complaint numbers NJ 169201, 169245, and 170494. The complaints were substantiated as deficiencies were cited related to survey result accessibility and environmental concerns.
Findings
Deficiencies were cited related to failure to make survey results readily accessible to residents and visitors, unsafe and unsanitary environment conditions, food safety violations, and multiple life safety code violations including fire door labeling, means of egress, and fire door inspections. The facility was found to be in substantial compliance with emergency preparedness but had multiple deficiencies in other areas.

Deficiencies (10)
Facility failed to make survey results readily accessible to residents and visitors.
Facility failed to maintain a clean, safe, and sanitary environment for 2 of 3 units' floors.
Facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness.
Facility failed to provide two-hour fire resistance-rated elements and assemblies in accordance with NFPA 101.
Facility failed to provide guards at exit ramps in accordance with NFPA 101 Life Safety Code.
Facility failed to provide exit doors in the means of egress readily accessible and free of all obstructions or impediments.
Facility failed to provide required instructional signage for K-type fire extinguishers.
Facility failed to ensure fire doors were inspected annually by a qualified person.
Facility failed to ensure smoke control systems were maintained in a safe operating condition.
Facility failed to provide electrical policy for patient care related electrical equipment and maintain required testing and maintenance documentation.
Report Facts
Census: 152 Total Capacity: 162 Number of Deficiencies: 10 Completion Dates: Various completion dates for plans of correction range from 01/15/2025 to 03/01/2026.

Inspection Report

Annual Inspection
Deficiencies: 3 Date: Dec 18, 2024

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, environmental safety, and food safety during the annual survey of the nursing home.

Findings
The facility was found deficient in making survey results accessible to residents, maintaining a clean and safe environment on two units, and ensuring proper kitchen sanitation and food storage. Specific issues included inaccessible survey results, dirty medication carts and mechanical lifts, stained linen carts, and improper refrigerator and freezer temperatures leading to disposal of food.

Deficiencies (3)
Failed to make survey results readily accessible to residents and visitors.
Failed to maintain a clean, safe, and sanitary environment on 2 of 3 units (2nd floor and [NAME] Hall), including hair and debris on medication carts and mechanical lifts, stained linen carts, and damaged linen cart covers.
Failed to maintain kitchen sanitation and proper food storage temperatures, resulting in food spoilage and disposal due to refrigerator and freezer temperatures being above safe levels.
Report Facts
Residents interviewed: 5 Temperature freezer: 42 Temperature refrigerator: 52 Date of survey completion: Dec 23, 2024

Employees mentioned
NameTitleContext
Licensed Nursing Home Administrator (LNHA)Interviewed regarding location and accessibility of survey results
Regional Nurse (RN)Interviewed regarding location and accessibility of survey results
Registered Nurse/Unit Manager (RN/UM #1)Interviewed about survey results location and environmental concerns
Registered Nurse/Unit Manager (RN/UM #2)Interviewed about survey results location and availability
Director of Nursing (DON)Interviewed about environmental concerns and cleaning responsibilities
Assistant Director of Nursing (ADON)Interviewed about environmental concerns
Licensed Practical Nurse/Unit Manager (LPN/UM #1)Observed and reported on resident pantry refrigerator/freezer temperatures and food disposal

Inspection Report

Complaint Investigation
Census: 150 Capacity: 162 Deficiencies: 7 Date: Sep 28, 2023

Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health due to complaints and recertification requirements.

Complaint Details
Multiple complaints were investigated with some substantiated deficiencies at tags F584 and F600 related to safe environment and freedom from abuse. Several complaints were unsubstantiated with no citations.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B, with deficiencies related to safe environment, freedom from abuse, comprehensive care planning, accident hazards, nutrition/hydration, and life safety code violations. Several complaints were substantiated with deficiencies.

Deficiencies (7)
Facility failed to provide a clean and sanitary environment for residents, including room disrepair and stained linens.
Facility failed to protect residents from abuse and neglect, including failure to follow incident reporting protocols.
Facility failed to develop and implement comprehensive person-centered care plans for residents.
Facility failed to ensure adequate supervision and assistance devices to prevent accidents and falls.
Facility failed to maintain nutrition and hydration status, including failure to provide prescribed nutrition interventions and proper food service.
Facility failed to maintain fire alarm system and smoke barriers in accordance with NFPA codes.
Facility failed to ensure oxygen cylinders were stored safely and separated from combustible materials.
Report Facts
Survey Dates: 2023-09-25 to 2023-09-28 Sample Size: 30 Supplemental Residents: 0 Occupied Beds: 148 Total Licensed Capacity: 162 Residents Reviewed: 33 Residents Reviewed for Falls: 33 Residents Reviewed for Nutrition: 33 Residents Reviewed for Abuse: 7 Residents Reviewed for Oxygen Storage: 53 Residents Potentially Affected by Fire Alarm Deficiency: 148

Employees mentioned
NameTitleContext
Licensed Practical Nurse 12Licensed Practical NurseNamed in abuse incident report failure to follow protocol
Certified Nurse Aide 4Certified Nurse AideInterviewed regarding resident interactions and abuse allegations
Registered Nurse 18Registered NurseInterviewed regarding resident interactions and abuse allegations
Unit Manager 20Unit ManagerInterviewed regarding resident interactions and abuse allegations
Director of NursingDirector of NursingInterviewed regarding abuse incident and falls protocol
Food Service DirectorFood Service DirectorInterviewed regarding food service and nutrition deficiencies
DietitianRegistered DietitianInterviewed regarding nutrition and meal service
Maintenance DirectorMaintenance DirectorInterviewed regarding fire alarm and oxygen storage deficiencies

Inspection Report

Complaint Investigation
Deficiencies: 7 Date: Sep 28, 2023

Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to provide a clean and sanitary environment, protect residents from abuse, prevent pressure ulcers, ensure proper fall reporting, secure urinary catheters, provide adequate nutrition, and serve palatable food.

Complaint Details
The investigation was complaint-driven based on multiple complaints including NJ164242 regarding unsanitary environment, NJ167015 regarding physical abuse, and other complaints related to pressure ulcers, falls, catheter care, nutrition, and food palatability.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and sanitary environment for residents, failure to protect residents from physical abuse, inadequate pressure ulcer prevention and care, failure to properly assess and report falls, improper catheter care, failure to provide prescribed nutrition interventions for significant weight loss, and failure to serve palatable and appropriately prepared food.

Deficiencies (7)
Failed to provide a clean and sanitary environment for one resident's room with issues including bent window screen, white patches on walls, dirty floors, plaster missing around air conditioner, mold, stained curtains and bed linens.
Failed to protect a resident from physical abuse by another resident, resulting in skin tear and bruising.
Failed to implement timely pressure ulcer prevention and care measures for one resident, resulting in worsening of a pressure ulcer to stage IV.
Failed to assess, notify supervisor, and complete incident report after a resident fall, resulting in delayed identification of wrist fracture.
Failed to properly secure indwelling catheter drainage tubing with leg straps for two residents, risking urinary tract infections and bladder harm.
Failed to provide prescribed nutrition interventions including double portions and fortified foods for a resident with significant weight loss.
Failed to serve food that was palatable, at appropriate temperature, and nonrepetitive for five residents, with complaints of bland, dry, repetitive meals and inappropriate food consistency.
Report Facts
Residents reviewed: 33 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 2 Residents affected: 1 Residents affected: 5 Weight loss percentage: 15.7 Pressure ulcer measurements: 3 Pressure ulcer measurements: 2 Pressure ulcer measurements: 5 Resident weight: 118

Employees mentioned
NameTitleContext
LPN12Licensed Practical NurseInvolved in fall incident with Resident R46 and delayed incident reporting
Maintenance DirectorMaintenance DirectorConfirmed room disrepair and sanitation issues in Resident R14's room
Director of HousekeepingDirector of HousekeepingAcknowledged poor cleaning and replacement of curtains and linens in Resident R14's room
AdministratorAdministratorExpressed expectations for building upkeep and cleanliness
RN18Registered NurseInterviewed regarding Resident R79's behavior
RN17Registered NurseInterviewed regarding Resident R79's behavior and incident day
UM20Unit ManagerDiscussed Resident R72 and R79 altercation and incident investigation
CNA6Certified Nursing AssistantInterviewed about care for Resident R30 including repositioning and heel protectors
CNA7Certified Nursing AssistantInterviewed about repositioning of Resident R30
LPN16Licensed Practical NurseInterviewed about Resident R30's heel protectors and air mattress settings
Director of NursingDirector of NursingInterviewed about pressure ulcer care and wound progression for Resident R30
Medical DirectorMedical DirectorInterviewed about expectations for repositioning and heel protectors for Resident R30
LPN22Licensed Practical NurseObserved catheter care and Foley bag management for Resident R18
UM21Unit ManagerConfirmed lack of Foley catheter leg straps for Residents R1 and R18
CNA23Certified Nursing AssistantVerified lack of Foley catheter leg straps for Residents R1 and R18
Dietary Aide DA1Dietary AideObserved serving food portions and utensils on tray line
Dietary Aide DA2Dietary AideDiscussed fortified diets and tray line food items
Dietary DirectorDietary DirectorDiscussed food fortification, tray line items, and food quality issues
Registered DietitianRegistered DietitianDiscussed resident nutrition, weight loss, and food service issues

Inspection Report

Complaint Investigation
Deficiencies: 7 Date: Sep 28, 2023

Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to provide a clean and sanitary environment, protect residents from abuse, prevent pressure ulcers, ensure proper fall reporting, provide appropriate catheter care, and maintain adequate nutrition and food palatability.

Complaint Details
Complaint NJ164242 regarding unsanitary environment; Complaint NJ167015 regarding physical abuse; additional complaints related to pressure ulcers, falls, catheter care, nutrition, and food palatability.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and sanitary environment for residents, failure to protect residents from physical abuse, inadequate pressure ulcer prevention and care, failure to properly assess and report falls, improper catheter care with unsecured catheter tubing, failure to provide prescribed nutrition interventions for significant weight loss, and failure to serve palatable and appropriately prepared food.

Deficiencies (7)
Failed to provide a clean and sanitary environment for one resident's room with visible stains, holes, and mold.
Failed to protect a resident's right to be free from physical abuse after an altercation between residents.
Failed to implement timely pressure ulcer prevention and care measures, resulting in worsening of a pressure ulcer to stage IV.
Failed to assess, notify supervisors, and complete incident reports following a resident fall, resulting in delayed fracture diagnosis.
Failed to properly secure indwelling catheter drainage tubing with leg straps for two residents, risking urinary tract infections and bladder harm.
Failed to provide prescribed nutrition interventions including double portions and fortified foods for a resident with significant weight loss.
Failed to serve food that was palatable, at appropriate temperature, and nonrepetitive for multiple residents.
Report Facts
Residents reviewed: 33 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 2 Residents affected: 1 Residents affected: 5 Weight loss percentage: 15.7 Pressure ulcer size: 3 Pressure ulcer size: 3 Pressure ulcer size: 2

Employees mentioned
NameTitleContext
LPN12Licensed Practical NurseInvolved in fall incident with Resident R46 and delayed incident reporting
DONDirector of NursingInterviewed regarding pressure ulcer care and fall incident
MDMedical DirectorInterviewed regarding pressure ulcer care and repositioning
RDRegistered DietitianInterviewed regarding resident nutrition and food service issues
DDDietary DirectorInterviewed regarding food service and fortified diets
CNA6Certified Nursing AssistantInterviewed regarding pressure ulcer care for Resident R30
CNA7Certified Nursing AssistantInterviewed regarding pressure ulcer repositioning for Resident R30
LPN16Licensed Practical NurseInterviewed regarding pressure ulcer care and air mattress settings
UM20Unit ManagerInterviewed regarding resident altercation incident
LPN22Licensed Practical NurseObserved catheter care and Foley bag management for Resident R18
UM21Unit ManagerInterviewed regarding catheter care and leg strap use
CNA23Certified Nursing AssistantInterviewed regarding catheter leg strap use
AdministratorInterviewed regarding facility cleanliness expectations
Maintenance DirectorInterviewed regarding room disrepair and maintenance
Director of HousekeepingInterviewed regarding cleanliness and housekeeping practices
RN17Registered NurseInterviewed regarding resident behaviors and altercation
RN18Registered NurseInterviewed regarding resident behaviors
CNA4Certified Nurse AideInterviewed regarding resident behaviors

Inspection Report

Complaint Investigation
Census: 148 Deficiencies: 4 Date: Aug 18, 2023

Visit Reason
The inspection was conducted based on Complaint #NJ00166465 to investigate compliance with 42 CFR Part 483, Subpart B, for long term care facilities.

Complaint Details
Complaint #NJ00166465 was substantiated based on observations, interviews, and record reviews indicating multiple deficiencies in care and documentation.
Findings
The facility was found not in substantial compliance with requirements related to documentation of Activities of Daily Living (ADL) care, respiratory/tracheostomy care and suctioning, and resident records including lifesaving measures documentation. Deficiencies were identified in CNA staffing ratios and physician orders for oxygen therapy.

Deficiencies (4)
Failure to consistently document Activities of Daily Living (ADL) care for dependent residents.
Failure to obtain physician's order for respiratory care including tracheostomy and suctioning and failure to follow facility policy.
Failure to document lifesaving measures in resident medical records and maintain confidentiality and completeness of medical records.
Failure to maintain required minimum direct staff-to-resident ratios for Certified Nursing Assistants (CNA) on 5 of 14 day shifts.
Report Facts
Census: 148 Sample Size: 5 Deficient CNA staffing shifts: 5 CNA staffing required: 18 CNA staffing actual: 15 Date of revisit: Sep 27, 2023

Inspection Report

Complaint Investigation
Deficiencies: 3 Date: Aug 16, 2023

Visit Reason
The inspection was conducted based on complaint NJ00166465 to investigate allegations related to failure to consistently document Activities of Daily Living (ADL) care, failure to obtain physician's order for oxygen use, and failure to document lifesaving measures when a resident was found unresponsive.

Complaint Details
Complaint NJ00166465 involved allegations of failure to document ADL care, failure to obtain physician's order for oxygen, and failure to document lifesaving measures during a resident's death.
Findings
The facility failed to consistently document ADL care for two residents, failed to obtain and follow a physician's order for oxygen administration for one resident, and failed to document lifesaving measures and CPR in the medical record for one resident who died. These deficiencies were supported by observations, interviews, and medical record reviews.

Deficiencies (3)
Failure to consistently document Activities of Daily Living (ADL) care for residents #3 and #4 as per facility policy.
Failure to obtain a physician's order for oxygen use and failure to follow facility policy for oxygen administration for Resident #2.
Failure to document lifesaving measures and CPR in the medical record when Resident #1 was found unresponsive and died.
Report Facts
BIMS score: 9 BIMS score: 6 Oxygen flow rate: 3 BIMS score: 15 BIMS score: 9 Time CPR started: 630

Employees mentioned
NameTitleContext
LPN #1Licensed Practical NurseInterviewed regarding oxygen administration and documentation for Resident #2 and progress notes for Resident #1
LPN #3Licensed Practical Nurse/Unit ManagerObserved providing incontinence checks and interviewed about ADL care documentation
CNA #1Certified Nursing AssistantInterviewed about providing ADL care and reporting Resident #1 unresponsive
DONDirector of NursingInterviewed regarding expectations for ADL documentation, oxygen orders, and documentation of CPR
LPN #2Licensed Practical NurseInterviewed about care of Resident #1 on the evening before death and CPR documentation
RN/UMRegistered Nurse/Unit ManagerInterviewed about CPR expectations and documentation after Resident #1 was found unresponsive
LPN #4Licensed Practical NurseInvolved in attempts to revive Resident #1

Inspection Report

Routine
Deficiencies: 0 Date: Mar 21, 2023

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health on 3/21/2023 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.

Inspection Report

Deficiencies: 0 Date: Mar 21, 2023

Visit Reason
The document is a statement of deficiencies and plan of correction for Preferred Care at Absecon, summarizing the findings of a regulatory survey conducted on 2023-03-21.

Findings
No health deficiencies were found during the survey.

Inspection Report

Annual Inspection
Census: 143 Deficiencies: 9 Date: Jul 26, 2022

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 resident rights, nutrition and dietary services, accident hazards, infection control, dialysis orders, food safety and sanitation, garbage disposal, and antibiotic stewardship.

Deficiencies (9)
Facility failed to ensure residents were assisted to eat meals in a timely manner and dining experience promoted dignity and respect for 5 of 32 residents.
Facility failed to ensure consistent dietician assessments and obtain physician orders for dietary supplements for 2 residents.
Resident was found in possession of prohibited smoking supplies.
Resident's urinary catheter was not maintained properly; catheter bag was on floor and not covered.
Facility failed to maintain a current physician order for dialysis for 1 resident.
Facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner in the kitchen and resident pantry.
Facility failed to keep garbage compactor doors closed and loading dock area free of debris and cigarette butts.
Staff failed to wear appropriate personal protective equipment (gowns) in a resident's room under contact precautions.
Facility failed to implement antibiotic stewardship protocols to prevent unnecessary antibiotic use for 1 resident.
Report Facts
Census: 143 Sample size: 36 Number of residents reviewed for dining: 32 Number of residents reviewed for nutrition: 2 Number of residents reviewed for accident hazards: 1 Number of residents reviewed for catheter care: 1 Number of residents reviewed for dialysis: 1 Number of residents reviewed for infection control: 9

Employees mentioned
NameTitleContext
Regional Food Service DirectorInterviewed about meal tray delivery and food service procedures
Licensed Nursing Home AdministratorInterviewed about dining room seating and feeding assistance
Registered DieticianInterviewed about nutrition assessments and dietary supplement orders
Licensed Practical Nurse #3Interviewed about resident dietary supplement orders
Licensed Nurse/Unit Manager #1Interviewed about dietary supplement orders and feeding assistance
Certified Nursing Assistants (CNAs)Named in relation to feeding assistance and PPE deficiencies
Licensed Practical Nurse/Unit Manager #1Interviewed about resident possession of smoking supplies
Director of NursingInterviewed about infection control, dietary supplement orders, and PPE compliance
Infection PreventionistProvided education and audit plans for infection control and PPE compliance
Certified Nursing Assistant #1Interviewed about failure to wear gown during care

Inspection Report

Routine
Deficiencies: 9 Date: Jul 26, 2022

Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, nutrition, safety, infection control, and facility operations at Preferred Care at Absecon.

Findings
The facility was found deficient in multiple areas including failure to assist residents with timely meal service and dignity during dining, inconsistent assessment and physician orders for dietary supplements, unsafe possession of smoking supplies by a resident, improper urinary catheter care, lack of current dialysis orders, unsafe food handling and sanitation practices, inadequate garbage disposal, failure to ensure staff wore appropriate PPE under contact precautions, and failure to implement antibiotic stewardship protocols.

Deficiencies (9)
Failure to ensure residents were assisted to eat their meals in a timely manner and to promote dignity and respect during dining.
Failure to ensure consistent dietician assessment and obtain physician orders for dietary supplements for residents with weight loss and nutrition needs.
Failure to ensure a resident was not in possession of smoking supplies contrary to facility policy.
Failure to maintain urinary catheter drainage bag with privacy cover, off the floor, and below bladder level.
Failure to maintain a current physician order for dialysis for a resident receiving dialysis.
Failure to handle potentially hazardous foods and maintain sanitation to prevent foodborne illness, including wet nesting of pans, uncovered plates, unlabeled food, and improper storage.
Failure to keep garbage compactor closed and loading dock area free of debris and cigarette butts.
Failure to ensure staff wore appropriate personal protective equipment (gowns) when providing care under contact precautions.
Failure to implement antibiotic stewardship protocols, resulting in continuation of an ineffective antibiotic against a resistant bacteria.
Report Facts
Residents reviewed for dining: 32 Residents affected: 5 Meal truck delivery times: Breakfast trucks delivered at 8:15 AM and 8:30 AM; lunch trucks at 12:15 PM and 12:30 PM Weight measurements: Resident #113 weights ranged from 98.0 to 105.0 lbs over 6 months Dates of dietary notes: Last nutrition note for Resident #113 was 2/28/2022; next note on 7/19/2022 Cigarette butts counted: 25

Employees mentioned
NameTitleContext
RN/UM #1Registered Nurse/Unit ManagerInterviewed regarding dietary supplement orders and feeding assistance
LPN/UM #1Licensed Practical Nurse/Unit ManagerConfirmed smoking supplies policy and assisted with resident room observation
Regional Food Service DirectorFood Service DirectorInterviewed regarding meal tray sorting and food service procedures
Director of NursingDirector of NursingInterviewed regarding dietary assessments, smoking policy, catheter care, PPE use, and antibiotic stewardship
Infection PreventionistInfection PreventionistConfirmed PPE requirements and antibiotic stewardship practices
CNA #1Certified Nursing AssistantObserved not wearing gown during care under contact precautions

Inspection Report

Life Safety
Deficiencies: 6 Date: Jul 25, 2022

Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 07/25 and 07/26/2022 to assess compliance with Medicare/Medicaid participation requirements and the 2012 NFPA 101 Life Safety Code for Preferred Care at Absecon.

Findings
The facility was found to have multiple life safety deficiencies including failure of stairwell doors to maintain fire resistance rating, hazardous area doors not self-closing, improperly installed portable fire extinguishers, corridor doors not resisting smoke passage, breaches in smoke barrier walls, and malfunctioning bathroom exhaust ventilation systems.

Deficiencies (6)
Two of sixteen exit stairwell doors failed to positive latch into their frames, compromising the two-hour fire rated construction.
Fire-rated doors to hazardous areas were not self-closing and lacked proper separation by smoke-resisting partitions, specifically the medical records room door.
Twelve of forty-three portable fire extinguishers were installed below the required height, violating NFPA 10 installation standards.
One corridor door to a resident room did not close properly, leaving a one-inch gap allowing passage of smoke and fire.
Two of seven smoke barrier walls had penetrations with unsealed holes allowing smoke, fumes, and fire to pass through.
Four of fifteen resident bathroom exhaust systems were not functioning properly, failing to provide required mechanical ventilation.
Report Facts
Fire rated stairwell doors tested: 16 Portable fire extinguishers inspected: 43 Resident rooms inspected for bathroom exhaust: 15 Smoke barrier walls inspected: 7 Resident room doors inspected: 15

Employees mentioned
NameTitleContext
Director of MaintenancePresent during observations and confirmed findings

Inspection Report

Complaint Investigation
Census: 128 Deficiencies: 0 Date: Oct 20, 2021

Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health based on complaints NJ149124, NJ149391, and NJ149474.

Complaint Details
Complaint numbers NJ149124, NJ149391, and NJ149474 were investigated. The facility was found to be in substantial compliance with infection control requirements.
Findings
The facility was found to be in substantial compliance with 42 CFR §483.80 infection control regulations related to COVID-19 and the requirements of 42 CFR Part 483, Subpart B for long term care facilities based on this complaint visit.

Report Facts
Sample size: 6

Inspection Report

Complaint Investigation
Census: 99 Deficiencies: 0 Date: Aug 3, 2021

Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ144042, NJ143936, NJ142696, and NJ134968.

Complaint Details
Complaint numbers NJ144042, NJ143936, NJ142696, and NJ134968 were investigated and found to be 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: 9

Inspection Report

Routine
Census: 123 Deficiencies: 0 Date: Feb 17, 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: 8

Inspection Report

Complaint Investigation
Census: 134 Deficiencies: 2 Date: Jan 21, 2021

Visit Reason
The inspection was conducted as a complaint survey based on multiple complaints (NJ136404, NJ139598, NJ140308, NJ138537) to assess compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.

Complaint Details
The visit was complaint-driven based on four complaint numbers. The facility was found not in compliance with infection control and visitation policies during the COVID-19 pandemic, with substantiated deficiencies related to glove use and visitation restrictions.
Findings
The facility was found non-compliant with infection prevention and control requirements, specifically failing to ensure staff changed gloves during incontinent care for one resident and failing to prohibit indoor visitation during Phase 0 of reopening amid a COVID-19 outbreak. The facility was in Phase 0 with active COVID-19 cases and did not follow NJDOH directives regarding visitation restrictions.

Deficiencies (2)
Failure to ensure staff changed gloves while providing incontinent care for Resident #3, including not washing hands before or after care.
Failure to prohibit indoor visitation during Phase 0 of reopening for Resident #6, contrary to NJDOH Executive Directive No. 02-026-1.
Report Facts
Census: 134 Sample Size: 6 COVID-19 positive residents: 5 Total residents with COVID-19: 14 Glove change re-education completion date: 2021

Employees mentioned
NameTitleContext
CNA #1Certified Nurse AideNamed in deficiency for failing to change gloves and wash hands during incontinent care
Unit Manager #1Unit ManagerObserved providing care with CNA #1
DONDirector of NursingInterviewed regarding visitation policies and COVID-19 status
Infection PreventionistInfection PreventionistInterviewed regarding infection control and visitation policies
AdministratorFacility AdministratorInvolved in visitation policy discussion and corrective actions

Inspection Report

Routine
Census: 134 Deficiencies: 0 Date: Jan 20, 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: 5

Inspection Report

Routine
Census: 95 Deficiencies: 0 Date: Dec 9, 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.

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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