Inspection Reports for
Redbank Center For Rehabilitation And Healing
100 Chapin Avenue, Red Bank, NJ, 07701
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
13.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
158% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
81% occupied
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice outlines the types of information covered, reasons for use and disclosure of health information, individual rights regarding their health information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Listed as contact person for privacy practices and rights |
Inspection Report
Complaint Investigation
Census: 141
Capacity: 175
Deficiencies: 14
Date: Feb 27, 2025
Visit Reason
A Recertification and Complaint Survey was conducted due to complaints NJ181484 and NJ183544, focusing on compliance with long term care requirements and complaint allegations.
Complaint Details
Complaint numbers NJ181484 and NJ183544 triggered the survey. The facility was found not in substantial compliance based on these complaints.
Findings
The facility was found not in substantial compliance with federal requirements, with deficiencies in accuracy of assessments, coordination of PASARR and assessments, comprehensive care plans, ADL care, infection control, medication administration, and life safety code compliance. Immediate actions and plans of correction were initiated.
Deficiencies (14)
Accuracy of Assessments - Facility failed to ensure accurate Minimum Data Set (MDS) assessments for sampled residents.
Coordination of PASARR and Assessments - Facility failed to complete new level one PASARR assessments for residents with serious mental disorders.
Develop/Implement Comprehensive Care Plan - Facility failed to develop comprehensive care plans for sampled residents.
ADL Care Provided for Dependent Residents - Facility failed to ensure proper care for residents unable to carry out activities of daily living.
Activities Meet Interest/Needs Each Resident - Facility failed to provide activities according to assessments and care plans for sampled residents.
Quality of Care - Facility failed to ensure physician orders were followed for sampled residents, putting residents at risk.
Respiratory/Tracheostomy Care and Suctioning - Facility failed to administer respiratory care as prescribed for sampled residents.
Free from Unnecessary Psychotropic Meds/PRN Use - Facility failed to ensure PRN psychotropic drugs were limited and properly documented.
Food Procurement, Store, Prepare, Serve-Sanitary - Facility failed to ensure proper hand hygiene and food handling by staff.
Label/Store Drugs and Biologicals - Facility failed to ensure medication carts were locked and secure when unattended.
Medication Errors - Facility failed to ensure medication administration was error-free for sampled residents.
Infection Prevention & Control - Facility failed to ensure proper infection control practices and PPE use by staff.
Life Safety Code - Facility failed to ensure proper discharge from exits, sprinkler system maintenance, fire door inspections, and emergency generator manual stop station.
Utilities - Gas and Electric - Facility failed to ensure nonmetallic sheathed cable was properly concealed and extension cords were not used as permanent wiring.
Report Facts
Survey Census: 141
Total Capacity: 175
Sample Size: 32
Deficiency Count: 17
Date of Survey: Feb 27, 2025
Plan of Correction Completion Date: Apr 1, 2025
Inspection Report
Routine
Deficiencies: 1
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to evaluate medication administration practices and ensure medication error rates were less than 5 percent, focusing on compliance with medication administration timing and accuracy.
Findings
The facility failed to ensure medication administration was within the prescribed time frame and dosage, including late administration of gabapentin, administration of a discontinued medication (calcium acetate), and incorrect dosing of estradiol for one resident. These errors have the potential to cause adverse health outcomes.
Deficiencies (1)
Medication administration errors including gabapentin given 1 hour 39 minutes late, administration of discontinued calcium acetate, and incorrect estradiol dosage given to Resident 101.
Report Facts
Residents observed during medication administration: 32
Residents affected: 4
Medication administration error rate: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 2 | Administered medications late and incorrectly to Resident 101 | |
| Assistant Director of Nursing (ADON) | Provided interview statements regarding medication administration timing | |
| Director of Nursing (DON) | Provided interview statements regarding medication administration expectations |
Inspection Report
Routine
Deficiencies: 16
Date: Feb 27, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with federal and state regulations related to resident care, medication administration, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, incomplete care plans, improper incontinence care, inadequate provision of activities, failure to follow physician orders for skin protection and oxygen administration, medication errors, unsecured medication carts, improper infection control practices including failure to follow Enhanced Barrier Precautions, and incomplete medical record documentation related to resident discharge and death.
Deficiencies (16)
Failure to ensure accurate Minimum Data Set (MDS) assessments for residents resulting in potential unmet care needs.
Failure to complete required PASARR screenings for residents with psychiatric diagnoses.
Failure to develop and implement comprehensive care plans addressing residents' needs for vision, oxygen use, and skin protection boots.
Failure to provide proper incontinence care resulting in double briefing and risk of skin breakdown.
Failure to provide activities according to assessments and care plans for multiple residents, affecting social and mental status.
Failure to follow physician orders for skin protection boots and dressing changes, risking skin breakdown and infection.
Failure to administer oxygen at the prescribed dose, risking respiratory distress.
Failure to ensure meal or snack provision and ongoing communication for resident receiving dialysis, risking nutritional status.
Failure to ensure PRN psychotropic medication orders had required end dates, risking excessive medication administration.
Medication administration errors including late administration, administration of discontinued medication, and incorrect dosing.
Failure to keep medication carts locked when unattended, risking unauthorized access to medications.
Failure to follow proper hand hygiene and glove use in food service, risking spread of infection.
Failure to maintain complete medical records related to resident death and discharge, risking lack of communication and legal issues.
Failure to follow Enhanced Barrier Precautions (EBP) including hand hygiene, gown and glove use, and availability of isolation supplies, risking infection transmission.
Failure to use sterile technique and proper PPE when providing tracheostomy care and suctioning.
Failure to avoid touching medications with bare hands during administration.
Report Facts
Residents sampled: 32
Medication administration errors: 3
Dialysis communication forms reviewed: 19
Activity calendar events: 65
Activity calendar events: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Administered medications late and handled medications improperly |
| RN1 | Registered Nurse | Left medication cart unlocked multiple times and pronounced resident deceased without documentation |
| LPN5 | Licensed Practical Nurse | Failed to follow Enhanced Barrier Precautions during tracheostomy care and feeding tube administration |
| CNA4 | Certified Nursing Assistant | Unaware of care plan details and failed to apply skin protection boots |
| UM1 | Unit Manager | Responsible for care plan initiation and updating, acknowledged missing interventions for boots |
| DON | Director of Nursing | Provided expectations for care plans, medication administration, and infection control |
| IP | Infection Preventionist | Reported failures in infection control practices and PPE availability |
| DM | Dietary Manager | Reported dietary practices for dialysis residents |
| AD | Activity Director | Reported failures in providing activities according to care plans |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
Date: May 7, 2024
Visit Reason
The inspection was conducted in response to a complaint (NJ172093) to investigate staffing ratio compliance at the facility.
Complaint Details
Complaint #: NJ172093. The facility was found substantially non-compliant with staffing requirements during the complaint visit. The complaint was substantiated based on interviews and document review.
Findings
The facility was found to be deficient in meeting required Certified Nurse Aide (CNA) staffing ratios on 8 of 14 day shifts reviewed, potentially affecting all residents. The facility was not in compliance with New Jersey Administrative Code standards and must submit a Plan of Correction.
Deficiencies (1)
Failure to ensure staffing ratios were met for 8 of 14 day shifts reviewed, specifically CNA staffing below required minimums.
Report Facts
Census: 109
Deficient shifts: 8
Required CNAs: 13
Actual CNAs: 9
Resident counts: 102
Resident counts: 104
Resident counts: 106
Resident counts: 108
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Date: Jan 12, 2024
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health covering multiple complaint numbers from 01/10/2024 to 01/12/2024.
Complaint Details
Complaint survey conducted for complaint numbers NJ00156340, NJ00158547, NJ00162566, NJ00149170, NJ00151428, NJ001555333, NJ00156049, and NJ00156028. The facility was found to be deficient in CNA staffing for residents on 4 of 14 day shifts during 12/24/2023 to 01/06/2024. The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B based on this complaint visit.
Findings
The facility was found to be not in compliance with New Jersey Administrative Code staffing requirements, failing to meet minimum staff-to-resident ratios on 4 of 14 day shifts during the complaint period. The facility was otherwise in substantial compliance with federal long term care requirements based on this complaint visit.
Deficiencies (1)
Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 4 of 14 day shifts.
Report Facts
Census: 96
Sample size: 11
Deficient day shifts: 4
CNA staffing counts: 11
Residents on deficient days: 97
Residents on deficient days: 95
Residents on deficient days: 93
Required minimum CNAs: 12
Inspection Report
Annual Inspection
Census: 116
Deficiencies: 13
Date: Jan 11, 2023
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 failure to implement abuse policy for new employees, incomplete MDS assessments, nutrition and hydration status maintenance, physician visits, nurse aide performance reviews, pharmacy services, infection control, and life safety code violations including fire alarm system maintenance and elevator inspections.
Deficiencies (13)
Failure to implement abuse policy by ensuring all new employees were screened for potential abuse by conducting reference checks.
Failure to complete and submit discharge Minimum Data Set Assessments (MDS) for 17 of 17 residents.
Failure to maintain acceptable parameters of nutritional status for residents with significant weight loss.
Failure to ensure timely physician visits and supervision of care for residents.
Failure to complete yearly performance reviews of Certified Nursing Aides (CNAs).
Failure to provide routine and emergency drugs and biologics under supervision of licensed nurse.
Failure to maintain accurate ordering, receiving, and administration records of narcotic medications.
Failure to employ sufficient staff with appropriate competencies and skills for food and nutrition services.
Failure to properly dispose of garbage and maintain garbage dumpster areas.
Failure to maintain infection prevention and control program to prevent communicable diseases.
Failure to maintain means of egress free of obstructions and ensure fire alarm system maintenance.
Failure to maintain sprinkler system and conduct required inspections.
Failure to maintain elevator inspections and testing with firefighter recall.
Report Facts
Census: 116
Sample size: 27
Deficiencies cited: 14
Residents with incomplete MDS: 17
Residents reviewed for nutrition deficiency: 2
Residents reviewed for physician visit deficiency: 1
CNAs without performance reviews: 4
Garbage dumpsters with deficiencies: 5
Heat detectors not maintained: 2
Elevators inspected: 2
Inspection Report
Routine
Deficiencies: 13
Date: Jan 11, 2023
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations including abuse prevention, resident assessments, medication management, dietary services, infection control, and antibiotic stewardship.
Findings
The facility was found deficient in multiple areas including failure to conduct reference checks on newly hired employees, incomplete and late discharge Minimum Data Set assessments, failure to obtain weekly weights for residents with significant weight loss, failure to ensure timely physician face-to-face visits, lack of annual CNA performance evaluations, improper handling and documentation of controlled medications, inadequate food service management and dietary staffing, failure to accommodate resident dietary restrictions, improper food storage and sanitation practices, unsanitary garbage disposal areas, improper wound care technique, and lack of a fully implemented antibiotic stewardship program.
Deficiencies (13)
Failure to conduct reference checks for 4 of 5 newly hired employees as part of abuse prevention screening.
Failure to complete and submit discharge Minimum Data Set assessments for 17 residents within required timeframes.
Failure to obtain weekly weights as ordered for 2 residents with significant weight loss.
Failure to ensure physician face-to-face visits at required intervals for 1 resident.
Failure to conduct annual performance evaluations for 4 Certified Nursing Aides.
Pre-signing of DEA 222 narcotic order forms by Medical Director and failure to maintain completed forms properly.
Failure to accurately document administration of controlled medications for 2 residents.
Lack of certified Food Service Director and inadequate dietary staffing.
Failure to follow physician order for no cheese diet resulting in resident receiving cheese tortellini.
Failure to maintain dish machine at required sanitizing temperatures and maintain sanitary food storage and preparation areas.
Unsanitary garbage dumpster areas with debris and open lids.
Failure to maintain infection control during wound care treatment resulting in contamination of stoma.
Failure to implement a fully functional antibiotic stewardship program including staff education and monitoring.
Report Facts
Residents with incomplete discharge MDS: 17
Residents reviewed for weight loss: 2
CNA personnel files reviewed: 4
DEA 222 forms pre-signed: 4
Food insulator tops observed: 79
Dish machine final rinse temperature below 180 F: 10
Garbage dumpsters observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Assistant Director of Nursing | Named in abuse screening deficiency for lack of reference check. |
| Staff #2 | Director of Social Services | Named in abuse screening deficiency for lack of reference check. |
| Staff #3 | Housekeeper | Named in abuse screening deficiency for lack of reference check. |
| Staff #4 | Occupational Therapist | Named in abuse screening deficiency for lack of reference check. |
| Staff #5 | Occupational Therapist | Named in abuse screening deficiency for lack of reference check. |
| Licensed Practical Nurse | LPN | Named in wound care deficiency for contamination of stoma during treatment. |
| Director of Nursing | DON | Interviewed regarding DEA 222 forms and antibiotic stewardship program. |
| Regional Nurse | RN | Confirmed lack of reference checks, dietary staffing issues, and antibiotic stewardship program deficiencies. |
| Licensed Nursing Home Administrator | LNHA | Acknowledged multiple deficiencies including garbage area and dietary management. |
| Dietary Aide | DA | Acting Food Service Director without certification; involved in dietary deficiencies. |
| Infection Preventionist | IP/RN | Interviewed regarding antibiotic stewardship program deficiencies. |
Inspection Report
Complaint Investigation
Census: 129
Deficiencies: 2
Date: Aug 16, 2021
Visit Reason
The inspection was conducted based on a complaint (Complaint#: NJ146379) to investigate compliance with care planning and nursing assessment requirements.
Complaint Details
Complaint#: NJ146379. The facility was found not in substantial compliance based on this complaint visit.
Findings
The facility was found not in substantial compliance with requirements related to baseline person-centered care plans and nursing assessments. Specifically, the facility failed to develop a baseline care plan within 48 hours of admission and failed to have a registered nurse assess a resident on admission for 1 of 3 residents reviewed.
Deficiencies (2)
Failure to develop a baseline person-centered care plan within 48 hours of admission for 1 of 3 residents reviewed.
Failure to have a Registered Nurse assess a resident on admission for 1 of 3 residents reviewed.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 126
Deficiencies: 0
Date: May 5, 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: 5
Inspection Report
Routine
Census: 126
Deficiencies: 0
Date: Feb 24, 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 had implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 9
Inspection Report
Routine
Census: 128
Deficiencies: 0
Date: Jan 26, 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 and recommended COVID-19 practices.
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
Deficiencies: 6
Date: Oct 28, 2020
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, physician face-to-face visits, infection prevention and control practices, and proper documentation and care related to medication administration and resident care devices.
Findings
The facility was found deficient in transcribing physician orders correctly for medication administration, failing to obtain physician orders for use and care of a multipodus boot, not ensuring timely physician face-to-face visits and progress notes, improper disposal of sharps containers, failure to clean multi-use blood pressure cuffs between residents, and failure to properly clean and replace soiled privacy curtains.
Deficiencies (6)
Failure to transcribe orders correctly to electronic physician's orders and medication administration record for Resident #32.
Failure to obtain a physician's order to apply, monitor, and care for a resident wearing a multipodus boot (Resident #124).
Failure to ensure physician face-to-face visits and progress notes were conducted at least every 60 days for Resident #90 and others.
Improper disposal of sharps containers, including overfilled containers with sharps protruding beyond the fill line.
Failure to sanitize multi-use blood pressure cuff and pulse oximetry probe between residents during medication pass observation.
Failure to properly clean and replace soiled privacy curtains in resident rooms (Resident #24).
Report Facts
Physician Progress Notes missing: 5
Sharps containers overfilled: 5
Medication administration dates: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication order transcription errors and multipodus boot care. |
| LPN #2 | Licensed Practical Nurse | Observed not cleaning blood pressure cuff and pulse oximetry probe between residents. |
| RN/UM | Registered Nurse Unit Manager | Interviewed regarding multipodus boot care and physician order responsibilities. |
| DON | Director of Nursing | Interviewed regarding medication transcription, multipodus boot orders, infection control, and sharps disposal. |
| DMR | Director of Medical Records | Interviewed regarding missing physician face-to-face visits and progress notes. |
| Administrator | Facility Administrator | Interviewed regarding privacy curtain cleaning and sharps disposal procedures. |
| House-Keeping Director | House-Keeping Director | Interviewed regarding privacy curtain cleaning procedures. |
| DES | Director of Environmental Services | Interviewed regarding sharps container emptying and rounds. |
| UM #1 | Unit Manager | Interviewed regarding blood pressure cuff cleaning and sharps container management. |
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