Inspection Reports for
Reformed Church Home

Complaint # NJ 179632 was investigated. The investigation determined that the care plan was not followed for falls, but abuse could not be substantiated.

The facility failed to follow fall prevention interventions for Resident #44, resulting in a fall with injury. The investigation found that required floor mats were not in place and the bed was not in the lowest position at the time of the fall. Abuse was not substantiated, but the care plan was not followed.

Complaint # NJ 179632 was investigated. The facility failed to follow fall prevention interventions for Resident #44. The investigation did not substantiate abuse but confirmed the care plan was not followed.

The facility failed to follow fall prevention interventions for Resident #44, resulting in a fall with injury. The investigation found that required floor mats were not in place and the bed was not in the lowest position at the time of the fall. Abuse was not substantiated but the care plan was not followed.

Complaint investigation based on complaint numbers 169289, 179188, 179362, 179561. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities.

The facility was found not in substantial compliance with federal and state regulations. Deficiencies included failure to follow resident care plans leading to accident hazards, failure to maintain required minimum direct care staff ratios, fire safety code violations including non-compliant fire-rated doors and smoke barriers, and malfunctioning emergency communication systems in elevators.

The complaint investigation focused on failure to report and investigate an injury of unknown origin for Resident #21. The facility failed to report the injury to the New Jersey Department of Health and did not obtain statements from all staff involved in the resident's care. The Director of Nursing and Unit Manager concluded the injury was from the resident's drinking cup without adequate investigation.

The facility was found not in substantial compliance due to failure to report and thoroughly investigate an injury of unknown origin for Resident #21, failure to maintain required minimum direct care staff-to-resident ratios, failure to provide qualified LGBTQI+ and HIV+ training, failure to maintain sprinkler system integrity, corridor doors not resisting smoke passage, failure to perform required elevator firefighter service tests, failure to serve food at acceptable temperatures, and failure to maintain essential electrical system requirements.

The complaint investigation focused on Resident #21's bruise of unknown origin. The facility did not report the bruise to NJDOH and failed to obtain statements from all staff involved during the relevant shifts. The investigation was prematurely closed with a conclusion that the bruise was caused by a drinking cup without sufficient evidence. The Assistant Administrator and DON acknowledged incomplete investigation and failure to follow policy.

The facility failed to timely report a bruise of unknown origin to the New Jersey Department of Health and did not thoroughly investigate the bruise, missing statements from key staff and prematurely concluding the cause without sufficient evidence. Additionally, the facility failed to serve foods at an acceptable temperature for Resident #67 and the 2nd floor unit.

The facility failed to meet required staffing ratios for 16 of 42 shifts, with posted CNA to resident ratios exceeding mandated limits on day, evening, and night shifts. The facility acknowledged staffing shortages and implemented corrective actions including wage increases, signing bonuses, closing a subacute wing, and contracting with staffing agencies.

The facility failed to maintain a medication error rate below 5%, with two medication errors observed involving two nurses administering medications incorrectly. Additionally, the facility failed to minimize the potential spread of infection due to inadequate hand hygiene practices by nursing staff and a certified nursing assistant during medication administration and dining services.