Inspection Report Summary
The most recent inspection on November 21, 2025, identified deficiencies related to resident rights, environmental cleanliness, abuse reporting, care planning, food safety, and pest control. Earlier inspections showed a pattern of issues with maintaining a clean and homelike environment, staffing shortages, incomplete care plans, medication management, and infection control. Complaint investigations substantiated staffing deficiencies and abuse reporting delays, including a substantiated case of physical abuse in 2021. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s deficiencies have persisted over time with no clear pattern of overall improvement.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
165% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
207% occupied
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Nov 21, 2025
Visit Reason
The inspection was conducted based on complaints regarding resident rights, facility cleanliness, abuse reporting, care planning, food safety, and pest control.
Complaint Details
Complaint #185875 and others involved allegations of restricted resident rights, poor facility cleanliness, delayed abuse reporting, incomplete abuse investigations, inadequate care planning, food safety concerns, and pest infestations. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including restricting residents' access to outdoor areas, poor environmental cleanliness and maintenance, delayed and incomplete abuse reporting and investigations, inadequate care planning for a resident using a Life Vest, unclean and poorly maintained kitchen equipment, and ineffective pest control with fly infestations.
Deficiencies (7)
Failed to ensure resident rights were respected for residents who smoke and/or desire to go outside the facility, limiting outdoor access and smoking breaks.
Failed to maintain a safe, clean, comfortable, and homelike environment including cleanliness and repair of wheelchairs, air conditioning units, vents, door jams, shower rooms, and window screens.
Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities for four residents.
Failed to respond appropriately to all alleged violations, including incomplete investigations of abuse allegations for two residents.
Failed to develop and implement a comprehensive care plan for a resident using a Life Vest, lacking details on device cleanliness, hygiene, alarm response, and physician notification.
Failed to ensure kitchen ceiling vents, ice machine vent, and equipment were kept clean and/or in good repair, including unlatched food carts, rust, dust, and missing parts.
Failed to maintain an effective pest control program, resulting in fly and water bug infestations throughout the facility.
Report Facts
Residents smoking during group interview: 11
Residents on third floor: 57
Residents affected by pest infestation: 34
Residents receiving meals: 149
Total residents: 153
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in multiple interviews regarding resident rights, abuse reporting, and investigations. | |
| Director of Nurses | DON | Interviewed about resident rights and care planning. |
| Pavilion 1 Unit Manager | PAV1UM | Interviewed about smoking policy and care planning. |
| Activity Director | AD | Observed supervising smoking breaks and interviewed about resident smoking. |
| Business Office Manager | BOM | Interviewed about abuse reporting and resident financial exploitation. |
| Maintenance Director | MD | Interviewed about facility cleanliness and maintenance. |
| Environmental Director | ED | Interviewed about facility cleanliness and pest control. |
| Regional Nurse Consultant | Interviewed about abuse reporting and investigations. | |
| Regional Food Service Director | RFSD | Interviewed about kitchen cleanliness and equipment maintenance. |
| Minimum Data Set Coordinator | MDSC | Interviewed about care plan development. |
| Certified Nursing Assistant | CNA3 | Interviewed about pest sightings. |
| Certified Nursing Assistant | CNA4 | Interviewed about pest sightings. |
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 outlines 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
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for the notice |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 10, 2025
Visit Reason
The inspection was conducted based on complaint NJ180849 to determine if the facility maintained a clean and homelike environment for residents.
Complaint Details
Complaint NJ180849 was investigated and substantiated with findings of environmental deficiencies. The facility was unable to provide evidence that weekly environmental rounds were completed as required.
Findings
The facility failed to maintain a clean and homelike environment in two of three units, with observations including stains on ceiling tiles, holes in walls, build-up of dust and debris in heater vents, chipped paint, rust spots, and holes near toilets. The facility was unable to provide evidence that weekly environmental rounds were conducted as required.
Deficiencies (1)
Failure to maintain a clean and homelike environment including stains on ceiling tiles, holes in walls, build-up of dust and debris in heater vents, chipped paint, rust spots, and holes near toilets.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Director of Maintenance | Named in relation to responsibility for maintenance and acknowledgment of deficiencies. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Acknowledged findings and was involved in discussions about environmental rounds. |
| Housekeeping Director | Housekeeping Director | Mentioned as part of the team conducting environmental rounds. |
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 2
Date: Aug 14, 2024
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to maintain a clean and sanitary environment and insufficient nursing staff to meet residents' needs.
Complaint Details
Complaint numbers NJ 156940, 158956, 166158, 170632 related to environmental cleanliness and staffing shortages.
Findings
The facility was found deficient in maintaining a clean environment, with debris, stains, and buildup observed in multiple resident rooms and hallways. Additionally, the facility failed to provide sufficient nursing staff on a 24-hour basis, with documented CNA staffing shortages on multiple shifts over several weeks.
Deficiencies (2)
Failure to maintain the facility in a clean and sanitary environment, including debris and stains on floors, dark marks, hair knots, and unclean IV poles.
Failure to provide enough nursing staff every day to meet the needs of every resident; insufficient CNA staffing documented over multiple shifts.
Report Facts
CNA staffing: 14
CNA staffing: 16
CNA staffing: 12
CNA staffing: 10
CNA staffing: 5
CNA staffing: 10
CNA staffing: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Environmental Services and Laundry | Director of Environmental Services and Laundry (DEVS) | Interviewed regarding cleaning processes and responsibilities for cleaning IV poles and resident rooms. |
| Housekeeping Assistant | Housekeeping Assistant (HKA #1) | Interviewed about daily cleaning processes of resident rooms. |
| Housekeeping Assistant | Housekeeping Assistant (HKA #2) | Interviewed about responsibility for cleaning IV poles and acknowledged cleaning needs. |
| Staffing Coordinator | Staffing Coordinator (SC) | Interviewed about awareness of CNA staffing requirements and staffing patterns. |
| Director of Nursing | Director of Nursing (DON) | Interviewed about facility staffing patterns and confirmed housekeeping responsibilities. |
Inspection Report
Routine
Census: 32
Capacity: 180
Deficiencies: 6
Date: Aug 14, 2024
Visit Reason
Routine inspection conducted to assess compliance with federal and state regulations for long term care facilities, including resident rights, safe environment, comprehensive care plans, infection control, pharmacy services, and life safety code compliance.
Findings
The facility was found to be substantially compliant with many regulatory requirements but had deficiencies related to resident rights, safe environment, comprehensive care plans, pharmacy services, infection control, and life safety code. Deficiencies included improper resident transport, housekeeping issues, incomplete care plans, medication errors, inadequate infection control practices, and life safety code violations such as missing sprinkler heads and door locking mechanisms.
Deficiencies (6)
Resident #27 was improperly transported, violating resident rights.
Housekeeping staff failed to maintain sanitary and safe environment; multiple rooms had debris, stains, and unclean conditions.
Resident care plans were incomplete or not updated timely, affecting residents #372, #126, #137, and others.
Medication administration errors including expired medications, lack of proper documentation, and failure to follow physician orders.
Infection control program deficiencies including improper handling of soiled linens and lack of proper PPE use.
Life Safety Code violations including missing sprinkler heads, improper door locking mechanisms, and inadequate fire safety testing.
Report Facts
Census: 32
Total Capacity: 180
Deficiencies cited: 6
Inspection Report
Routine
Census: 173
Deficiencies: 12
Date: Aug 14, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident rights, environment, care planning, medication management, staffing, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure dignified transport of residents, maintain a clean environment, develop comprehensive care plans, ensure physician orders for hospital transfers and oxygen use, follow feeding tube protocols, maintain dialysis communication, provide adequate staffing, manage medications properly including expired drugs and controlled substances, and implement infection control practices.
Deficiencies (12)
Failed to ensure the transport of a non-ambulatory resident was provided in a manner to promote dignity and respect.
Failed to maintain the facility in a clean and sanitary environment including debris on floors, hair on medication cart wheels, and stained IV poles.
Failed to develop and implement a comprehensive person-centered care plan for respiratory care.
Failed to ensure residents had physician orders for hospital transfers.
Failed to follow physician orders to change feeding tube piston set every 24 hours.
Failed to ensure a resident using oxygen therapy at night had a physician order.
Failed to complete dialysis communication book for a resident on dialysis.
Failed to provide enough nursing staff on a 24-hour basis to meet resident needs, with documented CNA staffing deficiencies on multiple shifts.
Failed to ensure discontinued and expired medications were removed from active inventory and medication carts; failed to maintain accurate controlled substance counts; expired controlled medications found in automated dispensing system.
Failed to follow through on consultant pharmacist recommendations during monthly medication regimen reviews in a consistent and timely manner.
Failed to properly store and maintain sterile and non-sterile medical supplies in a safe and sanitary manner; failed to ensure laundry staff used appropriate personal protective equipment.
Failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness, including wet nesting of pans and lack of freezer temperature monitoring.
Report Facts
Residents present: 173
CNA staffing deficiency: 14
Overnight staff deficiency: 1
Expired fentanyl patches: 8
Medication regimen review compliance: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in expired medication and narcotic count findings |
| RN/UM #1 | Registered Nurse/Unit Manager | Named in medication management, care planning, and dialysis communication findings |
| DON | Director of Nursing | Named in multiple findings including staffing, medication management, and infection control |
| DEVS | Director Environmental Services and Laundry | Named in environmental cleanliness and laundry PPE findings |
| CP | Consultant Pharmacist | Named in medication management and expired medication findings |
| LPN/UM #1 | Licensed Practical Nurse/Unit Manager | Named in medication storage and food safety findings |
| SC | Staffing Coordinator | Named in staffing findings |
| CSD | Central Supply Director | Named in medication storage findings |
| IP | Infection Preventionist | Named in infection control and medication storage findings |
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 1
Date: Jul 15, 2024
Visit Reason
The inspection was conducted based on complaints NJ175506 and NJ175586 to investigate staffing ratio compliance at the facility.
Complaint Details
Complaint #: NJ175506, NJ175586. The complaint investigation determined the facility failed to meet staffing ratios as required by New Jersey law. The deficiency was substantiated with detailed staffing data from 06/30/2024 to 07/13/2024.
Findings
The facility was found not in compliance with New Jersey staffing requirements, failing to meet minimum Certified Nurse Aide (CNA) staffing ratios on 14 of 14 day shifts and 2 of 14 evening shifts reviewed. No negative outcomes to residents were identified, but all residents had the potential to be affected.
Deficiencies (1)
Failure to ensure staffing ratios were met for 14 of 14 day shifts and 2 of 14 evening shifts reviewed.
Report Facts
Census: 169
Deficient day shifts: 14
Deficient evening shifts: 2
Required CNAs per day shift: 21
Actual CNAs on 06/30/24 day shift: 11
Required total staff per evening shift: 17
Actual total staff on 06/30/24 evening shift: 13
Inspection Report
Routine
Census: 154
Deficiencies: 0
Date: Aug 10, 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 has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
The inspection was conducted as an annual survey of the River Front Rehabilitation and Healthcare Center to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 5, 2023
Visit Reason
The survey was conducted as a Life Safety Code Survey related to a new construction and renovation project involving the Phase 3 conversion of a main dining room into a newly renovated Rehabilitation Gym and Dining Room on the first floor.
Findings
The facility was found to be in compliance with Medicare/Medicaid participation requirements for Life Safety from Fire and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19 for existing health care occupancies in the renovated areas.
Report Facts
Percentage of building powered by generator: 50
Building stories: 3
Number of smoke zones: 8
Inspection Report
Annual Inspection
Census: 155
Capacity: 182
Deficiencies: 15
Date: Dec 16, 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 comprehensive assessments, care planning, medication management, food safety, infection control, staffing, and life safety code compliance. The facility was found to be substantially compliant with emergency preparedness.
Deficiencies (15)
Failure to conduct comprehensive assessments accurately and timely for residents.
Failure to develop and implement comprehensive person-centered care plans.
Failure to meet professional standards for services provided.
Failure to provide care to dependent residents consistent with their needs.
Failure to ensure psychotropic drugs are used appropriately with proper monitoring and documentation.
Failure to procure, store, prepare, and serve food in accordance with food safety standards.
Failure to dispose of garbage and refuse properly, resulting in unsanitary conditions.
Failure to conduct and document a comprehensive facility assessment including COVID-19 related resources and procedures.
Failure to establish and maintain an effective infection prevention and control program including contact tracing and COVID-19 testing.
Failure to maintain required minimum direct care staff-to-resident ratios for day shifts.
Failure to obtain criminal background check prior to date of hire for new employees.
Failure to ensure annual inspection of fire doors and missing required inspection tags.
Failure to maintain self-closing devices on stairway exit doors.
Failure to label stairway exit doors with fire rating.
Failure to perform smoke detection sensitivity testing as required.
Report Facts
Deficiencies cited: 15
Residents present: 155
Total licensed capacity: 182
CNA staffing shortfall: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ICP #1 | Infection Preventionist | Named in findings related to incomplete contact tracing and COVID-19 testing documentation. |
| Director of Nursing | Director of Nursing | Named in staffing and infection control findings and interviews. |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Named in background check deficiency. |
| Maintenance Director | Maintenance Director | Named in fire door inspection and fire alarm system deficiencies. |
| Director of Human Resources | Director of Human Resources | Named in background check deficiency. |
Inspection Report
Routine
Deficiencies: 11
Date: Dec 16, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey of River Front Rehabilitation and Healthcare Center to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, and facility operations.
Findings
The survey identified multiple deficiencies including failure to complete accurate resident assessments, untimely updates to care plans, inadequate neuro checks and medication administration, failure to provide proper hygiene care, incomplete wound care documentation, improper food handling and sanitation, incomplete COVID-19 outbreak management and testing, and failure to maintain a sanitary environment.
Deficiencies (11)
Failed to complete a resident assessment that accurately reflected the resident's status, specifically for Resident #15's right plantar foot wound.
Failed to update residents' comprehensive care plans in a timely manner for Residents #119 and #141.
Failed to accurately document neuro checks and follow physician orders for compression stockings for Residents #37 and #15.
Failed to provide finger nail care to Resident #64 who was dependent on staff for hygiene.
Failed to accurately identify wound type and clarify implementation of diagnostic study for Resident #15's pressure ulcer.
Failed to adequately monitor target behaviors for psychotropic medication use for Residents #86 and #115.
Failed to verify and accurately transcribe readmission medications for Resident #80, resulting in medication errors.
Failed to handle potentially hazardous foods and maintain sanitation, including wet nesting of pans, undated food containers, dented cans, uncovered coffee filters, and improper food temperature documentation.
Failed to maintain a sanitary environment by leaving the trash compactor doors open and garbage and debris scattered in the outside garbage receptacle area.
Failed to include resources for management of an active COVID-19 outbreak in the Facility Assessment and failed to conduct complete contact tracing and testing.
Failed to perform COVID-19 testing on residents and staff in accordance with facility policy and CDC guidelines during an outbreak.
Report Facts
Residents reviewed: 31
Residents reviewed: 34
Residents reviewed: 5
Residents reviewed: 2
Residents reviewed: 1
Residents tested: 13
Residents tested: 6
Residents tested: 3
Residents tested: 8
Residents tested: 8
Residents tested: 154
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #2 | MDS Coordinator | Named in deficiency related to inaccurate resident assessment and wound documentation |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Named in deficiency related to incomplete neuro checks |
| Licensed Practical Nurse Unit Manager (LPN/UM) #2 | Licensed Practical Nurse Unit Manager | Named in deficiency related to compression stocking refusal documentation |
| Licensed Practical Nurse Unit Manager (LPN/UM) #3 | Licensed Practical Nurse Unit Manager | Named in deficiency related to psychotropic medication behavior monitoring |
| Licensed Practical Nurse (LPN) #3 | Licensed Practical Nurse | Named in deficiency related to psychotropic medication behavior monitoring |
| Licensed Practical Nurse (LPN) #4 | Licensed Practical Nurse | Named in deficiency related to hygiene care and refusal documentation |
| Certified Nursing Assistant (CNA) #4 | Certified Nursing Assistant | Named in deficiency related to COVID-19 positive staff and outbreak testing |
| Infection Control Preventionist (ICP) #1 | Infection Control Preventionist | Named in deficiency related to incomplete COVID-19 contact tracing and testing |
| Director of Nursing (DON) | Director of Nursing | Named in multiple deficiencies including COVID-19 outbreak management and testing oversight |
| Regional Registered Nurse (RRN) #1 | Regional Registered Nurse | Named in deficiency related to COVID-19 outbreak management and testing oversight |
| Wound care consult practitioner | Wound care consult practitioner | Named in deficiency related to wound care documentation |
| Primary care physician | Physician | Named in deficiency related to wound care and medication documentation |
| Food Service Director (FSD) | Food Service Director | Named in deficiency related to food handling and sanitation |
| Maintenance Director (MD) | Maintenance Director | Named in deficiency related to water testing for Legionella |
| Administrator | Administrator | Named in deficiency related to COVID-19 outbreak management and facility assessment |
Inspection Report
Life Safety
Census: 157
Capacity: 182
Deficiencies: 4
Date: Dec 9, 2022
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 12/09/22 to assess compliance with fire safety regulations and the 2012 Edition of the NFPA 101 Life Safety Code for existing health care occupancy.
Findings
The facility was found to be noncompliant with several Life Safety Code requirements including failure to inspect fire doors annually, missing self-closing devices on stairway exit doors, missing fire rating labels on stairway doors, and failure to complete smoke detection sensitivity testing. These deficiencies had the potential to affect all 157 residents.
Deficiencies (4)
Failed to ensure fire doors were inspected annually as required by NFPA 101 Life Safety Code (2012 edition) 7.2.1.15.
Failed to maintain means of egress for one stairway exit door missing a self-closing device in accordance with NFPA 101 Life Safety Code (2012 Edition) Sections 19.2.2.2.7.
Failed to maintain means of egress for one stairway exit door missing a fire rating label as required by NFPA 101 Life Safety Code (2012 Edition) Sections 19.3.1.1.
Failed to ensure smoke detection sensitivity testing was completed in accordance with NFPA 72 (2010 edition) section 14.4.5.3.2.
Report Facts
Residents present: 157
Total licensed capacity: 182
Deficiency correction completion date: Jan 30, 2023
Revisit date: Feb 9, 2023
Residents potentially affected by missing self-closing device and missing fire rating label: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and verified deficiencies related to fire door inspections, missing self-closing device, missing fire rating label, and smoke detector sensitivity testing | |
| Director of Maintenance | Provided fire alarm inspection and testing documentation and verified lack of smoke detection sensitivity testing |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Aug 11, 2022
Visit Reason
The inspection was conducted as a new construction/renovation project, specifically a Phase 3 renovation inspection of the Front Lobby and Administrative Offices.
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 special project survey. The inspected areas may not be occupied until formal notification by the Certificate of Need and Licensing Division is received.
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 11, 2022
Visit Reason
A Life Safety Code Survey was conducted as part of a new construction/renovation project (Phase 3 renovation of the Lobby and Administrative Offices) to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance due to improper installation of sprinkler heads in the sprinkler control valves room adjacent to the newly renovated lobby. Specifically, the sprinkler deflector was installed 25 inches below the insulation, exceeding the maximum allowed distance of 12 inches, constituting a fire safety hazard.
Deficiencies (1)
Improper installation of sprinkler heads in the sprinkler control valves room; sprinkler deflector was 25 inches below insulation, exceeding NFPA 13 installation requirements.
Report Facts
Distance of sprinkler deflector below insulation: 25
Maximum allowed distance: 12
Survey start time: 9.05
Survey exit time: 10.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | Requested to provide architectural plans during survey | |
| Director of Maintenance (DOM) | Present during inspection and confirmed sprinkler installation finding |
Inspection Report
Complaint Investigation
Census: 156
Deficiencies: 4
Date: Jul 31, 2022
Visit Reason
Complaint survey conducted due to multiple complaint intakes regarding alleged violations and quality of care concerns at the facility.
Complaint Details
Complaint Intake numbers NJ149050, NJ153795, NJ155485, NJ154063, NJ00149157, NJ149169, NJ150827, NJ151895, and NJ155888 triggered the complaint survey. The facility was found not in compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on these complaints.
Findings
The facility was found non-compliant with requirements related to timely reporting and investigation of injuries of unknown origin, proper medication administration and documentation, and maintaining mandated direct care staff-to-resident ratios. Specific deficiencies included failure to immediately report injuries of unknown origin, incomplete investigations, missed medication administration documentation, and insufficient certified nurse aide staffing on multiple shifts.
Deficiencies (4)
Failure to ensure an injury of unknown origin was immediately reported to the Administrator and State Survey Agency.
Failure to thoroughly investigate alleged violations of abuse, neglect, exploitation, or mistreatment and report results within required timeframes.
Failure to ensure necessary care and treatments were documented as provided in accordance with accepted standards of nursing practice and physician's orders, including medication administration and wound care.
Failure to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law, deficient in CNA staffing for 14 of 14 day shifts and 2 of 14 night shifts reviewed.
Report Facts
Census: 156
Sample Size: 14
Staffing Deficiency Counts: 14
Staffing Deficiency Counts: 2
Medication Administration Missed Initials: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in failure to report injury of unknown origin and failure to investigate. |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Interviewed regarding injury reporting and investigation expectations. |
| Administrator | Facility Administrator | Interviewed regarding staff expectations and staffing challenges. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration and documentation. |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding medication administration and resident care. |
| LPN #8 | Licensed Practical Nurse | Interviewed regarding care provided to residents with specific conditions. |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Interviewed regarding medication administration and care standards. |
Inspection Report
Routine
Census: 162
Deficiencies: 0
Date: Apr 26, 2022
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: 13
Inspection Report
Routine
Census: 159
Deficiencies: 0
Date: Oct 4, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations related to COVID-19.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 158
Deficiencies: 7
Date: Jul 30, 2021
Visit Reason
Complaint investigation based on multiple complaint intakes regarding facility compliance with regulations related to safe environment, abuse prevention, physical restraints, food temperature, privacy, and laundry services.
Complaint Details
Complaint Intake NJ145796, NJ142317, NJ145807, NJ146081, NJ145021. The investigation substantiated abuse allegations involving tied sleeves of a resident, failure to timely report abuse by four staff members, and other environmental and care deficiencies.
Findings
The facility was found non-compliant with multiple regulatory requirements including failure to maintain safe environment lighting, failure to prevent physical abuse and use of physical restraints, failure to timely report abuse, failure to serve food at palatable temperatures, failure to ensure privacy curtains provide full visual privacy, and failure to properly label resident clothing. Corrective actions and plans of correction were documented for each deficiency.
Deficiencies (7)
Facility failed to ensure ceiling lights were working on the even numbered side of the hallway affecting 18 residents.
Facility failed to keep a resident free from physical abuse; resident's sleeves were tied together by staff.
Facility failed to keep a resident free from physical restraints; resident's sleeves were tied together as a restraint.
Facility staff failed to timely report an allegation of physical abuse involving tied sleeves of a resident.
Facility failed to ensure food was served at palatable temperatures; test trays showed food temperatures below safe and appetizing levels.
Facility failed to ensure privacy curtain was free from damage and provided complete visual privacy; curtain was too short to wrap around resident's bed.
Facility failed to ensure resident's clothing was inventoried and labeled properly, leading to misappropriation of personal property.
Report Facts
Census: 158
Sample Size: 7
Number of residents affected by lighting deficiency: 18
Number of residents affected by abuse and restraint: 1
Number of employees suspended: 4
Food temperature measurements (Fahrenheit): 126
Food temperature measurements (Fahrenheit): 108
Food temperature measurements (Fahrenheit): 52
Food temperature measurements (Fahrenheit): 133
Number of eye holes in privacy curtain: 25
Number of hooks in ceiling rack: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in physical abuse and failure to report abuse findings |
| Housekeeper #3 | Housekeeper | Named in failure to report abuse |
| Housekeeper #7 | Housekeeper | Named in failure to report abuse |
| Temporary Nurse Aide #4 | Temporary Nursing Assistant | Named in failure to report abuse |
| Director of Maintenance | Interviewed regarding lighting and privacy curtain deficiencies | |
| Nursing Home Administrator | Interviewed regarding multiple deficiencies and corrective actions | |
| Assistant Food Service Director | Interviewed regarding food temperature deficiencies | |
| Housekeeping Supervisor | Interviewed regarding privacy curtain and laundry issues | |
| Social Worker | Interviewed regarding abuse and property misappropriation |
Inspection Report
Abbreviated Survey
Census: 160
Deficiencies: 0
Date: May 4, 2021
Visit Reason
A 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 the New Jersey Administrative Code, Chapter 8:39, Standards for Licensure of Long Term Care Facilities, infection control regulations.
Report Facts
Sample size: 4
Inspection Report
Routine
Census: 180
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.
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
Complaint Investigation
Census: 163
Deficiencies: 6
Date: Jan 14, 2021
Visit Reason
Complaint investigation based on multiple complaint numbers regarding compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Complaint Details
Complaint numbers NJ142174, NJ140792, NJ139779, NJ140462, NJ138263 triggered the survey. The facility was found not in compliance based on these complaints.
Findings
The facility was found non-compliant in several areas including failure to provide medical records timely, failure to notify responsible parties of resident falls, failure to follow physician medication orders, failure to investigate falls adequately, failure to ensure kitchen staff wore hair restraints and face masks, and failure to maintain infection prevention and control standards.
Deficiencies (6)
Failure to provide a copy of resident's medical records within the required timeframe.
Failure to notify the responsible party of a resident's fall.
Failure to follow physician's orders for medication administration.
Failure to investigate falls to determine causative factors and prevent future falls.
Failure to ensure kitchen staff wore hair restraints.
Failure to ensure kitchen staff wore face masks for source control during COVID-19 pandemic.
Report Facts
Census: 163
Sample Size: 9
Medication administration times: 5
Medication administration times: 4
Fall incident counts: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding failure of kitchen staff to wear hair restraints and face masks. |
| Administrator | Administrator | Interviewed regarding observations of kitchen staff and fall notifications. |
| Director of Nursing | Director of Nursing | Interviewed regarding fall notifications and medication administration. |
| Medical Record Coordinator | Medical Record Coordinator | Interviewed regarding delays in providing medical records. |
| Unit Manager #1 | Unit Manager | Interviewed regarding failure to notify family of resident fall. |
| Infection Preventionist | Infection Preventionist Nurse | Interviewed regarding fall investigations and infection control practices. |
| Regional Nurse | Regional Nurse | Interviewed regarding medication administration errors. |
Inspection Report
Routine
Census: 157
Deficiencies: 0
Date: Dec 17, 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 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: 158
Deficiencies: 0
Date: Nov 20, 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
Inspection Report
Routine
Deficiencies: 6
Date: Oct 6, 2020
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements including resident assessment data transmission, respiratory care, medication management, restorative nursing services, medical record maintenance, and infection control practices.
Findings
The facility failed to complete and transmit Minimum Data Set (MDS) assessments timely for some residents, did not provide appropriate respiratory care including timely changing of oxygen tubing, failed to act on consultant pharmacist recommendations timely, did not effectively document restorative nursing program orders, failed to maintain complete and accurate medical records for a deceased resident, and did not consistently follow infection control practices during medication administration.
Deficiencies (6)
Failure to complete and transmit Minimum Data Set (MDS) assessments in accordance with guidelines for 3 of 35 residents reviewed.
Failure to provide necessary respiratory care for changing oxygen tubing for 4 of 4 residents reviewed.
Failure to act on or respond to Consultant Pharmacist comments in a timely manner for 2 of 6 residents reviewed.
Failure to effectively document Restorative Nursing Program orders in the EMR for 4 of 15 residents reviewed.
Failure to maintain complete and accurate medical records for 1 of 1 residents who expired in the facility.
Failure to follow appropriate infection control practices including hand hygiene and disinfecting durable medical equipment during medication administration observation.
Report Facts
Residents reviewed for MDS assessments: 35
Residents with deficient respiratory care: 4
Residents reviewed for medication management: 6
Residents reviewed for restorative nursing documentation: 15
Residents expired: 1
Nurses observed for infection control: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed failing to perform hand hygiene and disinfect equipment properly during medication administration | |
| Director of Nursing (DON) | Director of Nursing | Provided statements regarding expectations for medication orders and documentation |
| Lead Registered Nurse MDS Coordinator (CRC) | Lead Registered Nurse MDS Coordinator | Interviewed regarding missing MDS assessments |
| Licensed Practical Nurse MDS Coordinator (LPN MDS Coordinator) | Licensed Practical Nurse MDS Coordinator | Interviewed regarding MDS scheduling and missing assessments |
| Infection Control Regional Nurse | Infection Control Regional Nurse | Interviewed regarding infection control practices and MDS assessment issues |
| MDS Consulting Company Supervisor | MDS Consulting Company Supervisor | Interviewed regarding MDS assessment oversight |
| Licensed Practical Nurse Unit Manager (LPN UM) | Licensed Practical Nurse Unit Manager | Interviewed regarding respiratory care and restorative nursing orders |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | Interviewed regarding restorative nursing splint use |
| Occupational Therapist (OT) | Occupational Therapist | Interviewed regarding restorative nursing orders and documentation |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed regarding medication order management and restorative nursing orders |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Interviewed regarding medication order management and restorative nursing orders |
| Licensed Practical Nurse (LPN) #3 | Licensed Practical Nurse | Interviewed regarding chart checks and restorative nursing orders |
| Licensed Practical Nurse (LPN) #4 | Licensed Practical Nurse | Interviewed regarding restorative nursing orders |
Viewing
Loading inspection reports...
