Deficiencies (last 6 years)
Deficiencies (over 6 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
83% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
88% occupied
Based on a May 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census 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 details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Complaint Investigation
Census: 158
Capacity: 180
Deficiencies: 16
Date: May 2, 2024
Visit Reason
Complaint investigations were conducted for multiple complaint numbers to determine compliance with federal and state regulations for long term care facilities.
Complaint Details
Complaint investigations were conducted for complaint numbers #157139, #157797, #159358, #167071, and #171606.
Findings
Deficiencies were cited in multiple areas including resident rights, advanced directives, abuse reporting, accuracy of assessments, pressure ulcer care, range of motion, dialysis care, medication administration, food safety, hospice services, infection control, and life safety code compliance.
Deficiencies (16)
Facility failed to protect resident rights by posting unauthorized signage on resident doors and failing to follow HIPAA privacy requirements.
Facility failed to update physician orders and care plans according to resident's advance directives (POLST).
Facility failed to report alleged abuse incidents timely to the New Jersey Department of Health and other authorities.
Facility failed to accurately code Minimum Data Set (MDS) assessments for residents.
Facility failed to follow physician orders and provide comprehensive care for pressure ulcers, including proper treatment, care plans, and hand hygiene.
Facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decline.
Facility failed to provide adequate dialysis monitoring and care consistent with professional standards.
Facility failed to provide accurate medication administration, reconciliation, and documentation, including failure to remove discontinued medications and maintain tamper seals.
Facility failed to maintain proper kitchen sanitation, clean equipment, safe food storage, and proper disposal of cooking oil.
Facility failed to maintain sanitary nursing unit kitchenettes and ice machines, including cleaning and replacing equipment as needed.
Facility failed to maintain water management program and accountability logs, including cleaning of shower heads and eyewash stations.
Facility failed to ensure concealed sprinkler escutcheon caps were not painted, violating fire safety code.
Facility failed to conduct required electrical outlet testing on schedule.
Facility failed to ensure hospice services were coordinated and documented properly between hospice and facility staff.
Facility failed to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey law.
Facility failed to maintain a safe, functional, sanitary, and comfortable environment in laundry and linen storage rooms and shower rooms.
Report Facts
Residents present: 158
Total licensed capacity: 180
Deficient CNA staffing day shifts: 28
Deficient CNA staffing evening shifts: 1
Deficient CNA staffing day shifts (specific weeks): 8
Deficient CNA staffing day shifts (specific weeks): 11
Deficient CNA staffing evening shifts (specific weeks): 1
Deficient CNA staffing day shifts (specific weeks): 7
Deficient CNA staffing day shifts (specific weeks): 2
Medication doses unaccounted: 13
Medication doses administered incorrectly: 6
Number of residents reviewed for hospice: 3
Number of residents reviewed for dialysis: 3
Number of residents reviewed for pressure ulcers: 5
Number of residents reviewed for range of motion: 3
Number of residents reviewed for medication regimen: 7
Number of kitchenettes inspected: 4
Number of shower rooms inspected: 2
Number of stairwell heaters with unsealed recessed heaters: 6
Number of electrical outlet testing years reviewed: 2
Number of painted sprinkler escutcheon caps: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies |
| LPN #3 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies |
| LPN #4 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies |
| LPN #5 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies |
| LPN #6 | Licensed Practical Nurse | Named in medication administration and documentation deficiencies |
| RN #1 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #2 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #3 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #4 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #5 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #6 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #7 | Registered Nurse | Named in medication administration and documentation deficiencies |
| RN #9 | Registered Nurse | Named in medication administration and documentation deficiencies |
| LPN #7 | Licensed Practical Nurse | Named in kitchen sanitation and fryer oil disposal deficiencies |
| Director of Housekeeping | Named in laundry and housekeeping sanitation deficiencies | |
| Food Service Director | Named in kitchen sanitation and fryer oil disposal deficiencies | |
| Maintenance Director | Named in sprinkler and electrical testing deficiencies | |
| Operations Director | Named in sprinkler and electrical testing deficiencies | |
| Administrator | Named in staffing and infection control deficiencies | |
| Risk Manager/Facility Educator | Named in multiple deficiencies including medication, infection control, and hospice services | |
| Licensed Practical Nurse | Named in hospice services documentation deficiencies | |
| Certified Nursing Assistant (CNA) | Named in infection control and resident care deficiencies | |
| Licensed Practical Nurse (LPN) | Named in hospice services and resident care deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report injuries of unknown origin for two residents and medication administration errors for another resident.
Complaint Details
Complaint #171606 regarding failure to timely report injuries of unknown origin for Residents #210 and #211 and medication errors for Resident #212. The complaint was substantiated with findings of late reporting and medication administration errors.
Findings
The facility failed to report injuries of unknown origin to the New Jersey Department of Health in a timely manner for two residents and failed to ensure a resident received as needed narcotic medication according to physician orders, resulting in medication errors involving incorrect dosages administered by multiple nurses.
Deficiencies (2)
Failure to timely report injuries of unknown origin for Residents #210 and #211 to the New Jersey Department of Health as required by facility policy.
Failure to ensure Resident #212 received prn narcotic medication in accordance with prescriber's orders, resulting in administration of incorrect dosages multiple times by different nurses.
Report Facts
Residents affected: 2
Residents affected: 1
Medication administration errors: 6
Medication doses administered: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Provided details on injury reporting process and investigation for Residents #210 and #211 | |
| Director of Nursing (DON) | Provided medication administration records and investigation details for Resident #212 | |
| Social Worker Director (SWD) | Interviewed regarding injury reporting and investigation process | |
| President of Clinical (VPC) | Acknowledged late reporting of injuries and medication errors | |
| Unit Manager/RN | Completed investigation of medication administration errors | |
| Registered Nurse (RN) #1 | Failed to remove discontinued medication bingo card leading to medication errors | |
| Licensed Practical Nurses (LPN) #1, #2, #3, #4 | Administered incorrect doses of medication multiple times |
Inspection Report
Routine
Deficiencies: 12
Date: May 2, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, advanced directives, injury reporting, resident assessments, pressure ulcer care, range of motion and mobility, dialysis services, pharmaceutical services, infection prevention and control, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy, failure to update code status orders, failure to timely report injuries of unknown origin, inaccurate resident assessments, inadequate pressure ulcer care, failure to follow functional maintenance program recommendations, inadequate dialysis monitoring, pharmaceutical service errors including narcotic reconciliation and documentation, improper kitchen sanitation and food storage, inadequate water management, and failure to maintain a safe and sanitary environment in laundry and shower areas.
Deficiencies (12)
Failure to protect resident privacy and independence by posting unauthorized signage on resident's door.
Failure to address Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders with appropriate follow-up and care plan updates.
Failure to timely report injuries of unknown origin to the New Jersey Department of Health for two residents.
Failure to accurately code Minimum Data Set (MDS) for isolation precautions for a resident with C. diff infection.
Failure to provide appropriate pressure ulcer care including following physician orders, care planning, weekly skin review accuracy, and infection control during wound treatment.
Failure to provide appropriate care to maintain or improve range of motion and mobility including failure to follow Functional Maintenance Program (FMP) recommendations for splints and range of motion exercises.
Failure to provide safe and appropriate dialysis care including inadequate monitoring and documentation of vital signs and access site status after hemodialysis.
Failure to provide pharmaceutical services in accordance with professional standards including inaccurate documentation of controlled substance removal, narcotic reconciliation errors, failure to remove discontinued medications, and failure to document vital signs for medication administration.
Failure to maintain proper kitchen sanitation, clean equipment, proper food storage, sanitary nursing unit kitchenettes, and proper disposal of cooking oil.
Failure to maintain a safe and sanitary environment in laundry and linen storage rooms and nursing unit shower rooms.
Failure to ensure consistent and documented coordination and communication between facility staff and hospice staff for a resident receiving hospice services.
Failure to maintain tube feeding hydration bag and urinary catheter drainage bag and tubing in a manner to prevent infection and maintain dignity.
Report Facts
Residents reviewed: 33
Residents reviewed: 28
Residents reviewed: 5
Residents reviewed: 3
Residents reviewed: 2
Residents reviewed: 2
Residents reviewed: 5
Residents reviewed: 2
Medication doses: 13
Medication doses: 63
Medication doses: 20
Medication doses: 6
Wound measurements: 9
Wound measurements: 7
Wound measurements: 1
Wound measurements: 2
Wound measurements: 3
Wound measurements: 1
Tube feeding hydration: 501
Tube feeding hydration rate: 85
Tube feeding total volume: 1350
Tube feeding rate: 80
Tube feeding total volume: 1250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in narcotic medication reconciliation and administration errors |
| LPN #2 | Licensed Practical Nurse | Named in narcotic medication reconciliation and administration errors |
| LPN #3 | Licensed Practical Nurse | Named in narcotic medication reconciliation and administration errors |
| LPN #4 | Licensed Practical Nurse | Named in narcotic medication reconciliation and administration errors |
| LPN #5 | Licensed Practical Nurse | Named in narcotic medication reconciliation and administration errors |
| LPN #6 | Licensed Practical Nurse | Named in narcotic medication reconciliation and administration errors |
| RN #1 | Registered Nurse | Named in narcotic medication reconciliation and administration errors |
| RN/UM | Registered Nurse/Unit Manager | Named in narcotic medication reconciliation and administration errors |
| LPN #9 | Licensed Practical Nurse | Named in medication administration and discontinued medication removal |
| DON | Director of Nursing | Named in multiple findings including narcotic reconciliation, infection control, and medication administration |
| FSD | Food Service Director | Named in kitchen sanitation and food safety findings |
| DH | Director of Housekeeping | Named in laundry and kitchenette sanitation findings |
| DoM | Director of Maintenance | Named in water management and environmental sanitation findings |
| DoO | Director of Operations | Named in water management and environmental sanitation findings |
| VPC | Vice President of Clinical | Named in multiple findings and interviews |
| LNHA | Licensed Nursing Home Administrator | Named in multiple findings and interviews |
| IP/LPN | Infection Preventionist/Licensed Practical Nurse | Named in infection control and water management findings |
| LPN/UM | Licensed Practical Nurse/Unit Manager | Named in narcotic medication reconciliation and administration errors |
| CD/RN | Clinical Director/Registered Nurse | Named in hospice services communication |
| DSS | Director of Social Services | Named in hospice services communication |
| LPN #7 | Licensed Practical Nurse | Named in medication storage inspection |
| LPN #8 | Licensed Practical Nurse | Named in medication administration documentation |
| RN #2 | Registered Nurse | Named in medication administration and narcotic reconciliation |
| RN #3 | Registered Nurse | Named in medication administration and narcotic reconciliation |
| RN #4 | Registered Nurse | Named in medication administration and narcotic reconciliation |
| RN #5 | Registered Nurse | Named in medication administration and narcotic reconciliation |
| RN #6 | Registered Nurse | Named in medication administration and narcotic reconciliation |
Inspection Report
Routine
Census: 161
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on behalf of 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 to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
Annual inspection survey completed to assess compliance with health regulations at Roosevelt Care Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 164
Deficiencies: 0
Date: Sep 7, 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
Deficiencies: 0
Date: Sep 7, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Roosevelt Care Center, summarizing the findings of a regulatory survey conducted on 09/07/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Census: 160
Deficiencies: 1
Date: Jun 9, 2023
Visit Reason
The inspection was conducted based on a complaint (NJ 00164733) alleging failure of the facility staff to report incidents of abuse, neglect, or injuries of unknown origin as required by regulations.
Complaint Details
Complaint NJ 00164733 was substantiated as the facility did not report incidents involving injuries of unknown origin for two residents as required by regulation.
Findings
The facility failed to report injuries of unknown origin involving two residents to the New Jersey Department of Health as required by federal and state regulations. Investigations revealed incidents where residents had injuries but the facility did not notify the appropriate authorities within the mandated timeframes.
Deficiencies (1)
Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source to the appropriate authorities within required timeframes.
Report Facts
Sample size: 3
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rick Manager | Assistant Director of Nursing (ADON) | Responsible for re-educating after-hours and weekend supervisors on reporting requirements. |
| Director of Nursing | Director of Nursing (DON) | Named in relation to failure to report incidents and responsible for auditing incident reports. |
| Licensed Practical Nurse #1 | LPN | Provided statement regarding observation of resident injury. |
| Licensed Practical Nurse #2 | LPN | Noticed injuries during medication administration. |
| Certified Nursing Assistant #1 | CNA | Reported observation of resident injury during rounds. |
| Certified Nursing Assistant #2 | CNA | Provided morning care and reported no noted changes in resident condition. |
| Unit Manager/Registered Nurse | UM/RN | Observed resident injury and provided information during survey. |
| Licensed Nursing Home Administrator | LNHA | Participated in interview explaining reporting responsibilities. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report injuries of unknown origin to the New Jersey Department of Health as required by policy.
Complaint Details
The investigation was complaint-driven, focusing on allegations of unreported injuries of unknown origin (bruises) for two residents. The complaint was substantiated as the facility failed to report these injuries to the NJDOH as required.
Findings
The facility failed to report injuries of unknown origin for two residents to the NJDOH. Resident #1 had a bruise on the forehead that was not reported despite investigation, and Resident #2 had multiple bruises and redness with no witnessed cause. The facility lacked documentation of reporting these incidents to the NJDOH, violating their abuse and injury reporting policy.
Deficiencies (1)
Failure to timely report suspected abuse or injury of unknown origin to the New Jersey Department of Health for Resident #1 and Resident #2.
Report Facts
Deficiencies cited: 1
Bruise size: 2
Bruise size: 3.5
Bruise size: 4
Bruise size: 3
Bruise size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed Resident #1 leaning against the wall and repositioned resident; involved in injury investigation |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Noticed discoloration on Resident #1's forehead and reported it to nurse |
| Registered Nurse #1 | Registered Nurse | Documented progress notes regarding Resident #1's injury |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Noticed redness and bruises on Resident #2 during medication administration |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Provided morning care to Resident #2 and did not notice changes; observed Resident #2's face laying on bed's side rail |
| Director of Nursing | Director of Nursing | Led investigation and acknowledged failure to report injuries to NJDOH |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Participated in interview regarding reporting responsibilities |
Inspection Report
Complaint Investigation
Census: 169
Deficiencies: 1
Date: Jul 29, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints (NJ 151228, 152246, 152424, 153710) regarding the facility's compliance with long term care regulations.
Complaint Details
Complaint # NJ 151228, 152246, 152424, 153710. The facility failed to report an incident involving Resident #6 as required and did not follow their policy for elopement/missing residents. Resident #6 left a doctor's office without authorization, and the facility was unaware until the police notified them. The complaint was substantiated based on interviews, medical record review, and facility documents.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, specifically failing to report an incident involving Resident #6 to the New Jersey Department of Health as required and not following their Elopement/Missing Residents Policy and Procedure. Resident #6 left a doctor's office without authorization or a doctor's order, and the facility failed to notify appropriate authorities timely.
Deficiencies (1)
Failure to report alleged violations involving Resident #6 to the New Jersey Department of Health and failure to follow the facility's Elopement/Missing Residents Policy and Procedure.
Report Facts
Census: 169
Sample Size: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Acknowledged the incident involving Resident #6 and the failure to report | |
| Unit Manager | Involved in searching for Resident #6 and provided statements about the incident | |
| Administrator | Acknowledged the safety concern and lack of authorization for Resident #6 leaving the doctor's office |
Inspection Report
Follow-Up
Census: 167
Deficiencies: 1
Date: Dec 29, 2021
Visit Reason
The visit was conducted to assess compliance with New Jersey staffing regulations following a prior deficiency related to failure to maintain required minimum direct care staff to resident ratios.
Findings
The facility was found deficient in Certified Nursing Aide (CNA) staffing for 13 of 14 day shifts and deficient in CNAs to total staff on 2 of 14 evening shifts during late November and early December 2021. Interviews with staff confirmed awareness of staffing requirements but difficulty meeting them consistently. The facility's staffing policy did not include the required minimum direct care staff to resident ratios.
Deficiencies (1)
Failure to maintain required minimum direct care staff to resident ratios for day and evening shifts as mandated by the State of New Jersey.
Report Facts
Residents: 167
CNA staffing deficiency: 13
CNA staffing deficiency: 2
Required CNAs: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staffing Coordinator | Interviewed regarding awareness of staffing ratios and facility efforts | |
| Director of Nursing | Interviewed regarding awareness of staffing ratios and facility compliance | |
| Licensed Nursing Home Administrator | Interviewed regarding awareness of staffing ratios and facility staffing levels |
Inspection Report
Routine
Deficiencies: 6
Date: Dec 29, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including pressure ulcer care, range of motion, respiratory care, dialysis services, and infection control.
Findings
The facility was found deficient in multiple areas including failure to consistently follow physician orders for pressure ulcer prevention and care, lack of accountability and documentation for restorative nursing programs and orthotic devices, inadequate respiratory care including improper handling of oxygen and nebulizer equipment, failure to adjust medication administration times for dialysis residents, and lapses in infection prevention and control practices including improper use of PPE and inadequate isolation area design.
Deficiencies (6)
Failure to consistently follow physician's orders for off-loading bilateral heels and pressure ulcer care, resulting in a stage IV pressure injury.
Failure to ensure accountability and documentation for restorative nursing program and orthotic device use for residents with limited range of motion.
Failure to maintain necessary respiratory care and services including proper handling and timely changing of oxygen and nebulizer tubing.
Failure to adjust medication administration times to accommodate dialysis schedules and lack of documentation for held medications.
Failure to provide and implement an effective infection prevention and control program, including improper use of PPE, inadequate isolation area design, and lapses in hand hygiene and equipment disinfection.
Failure to follow proper wound care procedures including hand hygiene, use of gloves, and disinfection of treatment surfaces.
Report Facts
Deficiencies cited: 6
Resident reviewed for pressure injury: 1
Residents reviewed for limited range of motion: 2
Residents reviewed for respiratory care: 1
Residents reviewed for dialysis services: 1
Residents reviewed for infection control: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN | Performed wound care on Resident #117 with improper hand hygiene and treatment procedures | |
| Director of Nursing | DON | Provided statements and acknowledged deficiencies related to wound care, restorative nursing, and respiratory care |
| Registered Nurse Unit Manager | RN/UM | Provided statements regarding respiratory care, restorative nursing, and dialysis medication administration |
| Certified Nursing Assistant | CNA | Reported discovery of pressure injury and provided care observations |
| Director of Rehabilitation | DOR | Provided information on restorative nursing program and PUI gym usage |
| Physical Therapy Assistant | PTA | Observed providing therapy in PUI gym with lapses in PPE use |
| Infection Preventionist | IP | Provided statements on infection control policies and PUI gym design |
| Licensed Practical Nurse | LPN | Performed wound care and provided statements on procedures |
| Housekeeping & Building Maintenance Director | HK/BMD | Provided statements on housekeeping infection control practices |
| Registered Nurse | RN | Administered medications and provided statements on dialysis medication timing |
| Licensed Nursing Home Administrator | LNHA | Provided facility policies and statements on quality assurance activities |
Inspection Report
Life Safety
Census: 165
Capacity: 356
Deficiencies: 3
Date: Dec 28, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health, Health Facility Survey and Field Operations to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the 2012 Edition of the NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including lack of emergency lighting above the emergency generator's transfer switch, obstructed exit signage, and failure to perform and document monthly firefighter service inspections on elevators.
Deficiencies (3)
Failed to provide battery backup emergency light above the emergency generator's transfer switch independent of the building's electrical system and emergency generator.
Failed to maintain exit directional signs illuminated and unobstructed, with one exit sign obstructed by ceiling-mounted light fixtures.
Failed to ensure elevators were inspected and tested monthly for firefighter service as required, with no records of monthly tests for 2 of 2 elevators.
Report Facts
Certified beds: 356
Census: 165
Exit signs observed: 14
Elevators inspected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Plant Operations Director | Verified emergency lighting deficiency and provided education on emergency lighting and elevator inspection requirements | |
| Administrator | Notified of findings at Life Safety Code exit conference |
Inspection Report
Complaint Investigation
Census: 167
Deficiencies: 0
Date: Oct 24, 2021
Visit Reason
The inspection was conducted as a complaint survey (Complaint #: NJ147259) to assess compliance with long term care facility regulations.
Complaint Details
Complaint #: NJ147259. The facility was found to be in compliance based on this complaint survey.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, based on this complaint survey. Additionally, a COVID-19 Focused Infection Control Survey found the facility compliant with infection control regulations and CDC recommended practices.
Report Facts
Sample Size: 8
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 0
Date: Jun 24, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ140616, NJ133458, NJ144291, NJ138526, and NJ140926.
Complaint Details
Complaint numbers NJ140616, NJ133458, NJ144291, NJ138526, NJ140926 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: 149
Deficiencies: 0
Date: Jan 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 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
Complaint Investigation
Census: 148
Deficiencies: 5
Date: Dec 10, 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 and COVID-19 related practices.
Complaint Details
The visit was complaint-related as it was a COVID-19 focused infection control survey triggered by concerns about infection prevention and control practices during the pandemic.
Findings
The facility failed to properly screen visitors for COVID-19 symptoms and temperature, did not follow proper PPE removal and disposal protocols, lacked designated housekeeping equipment on the COVID-19 positive unit, and had deficiencies in hand hygiene practices. Additionally, the facility failed to ensure COVID-19 testing compliance for an agency transport staff, lacked a policy for rapid antigen testing, and did not effectively track COVID-19 test results for staff.
Deficiencies (5)
Failed to appropriately screen visitors for COVID-19 symptoms and temperature using non-contact thermometers correctly.
Failed to ensure proper removal and disposal of personal protective equipment (PPE), including covered and emptied receptacles to prevent overflow.
Failed to provide designated housekeeping equipment on the COVID-19 positive cohort unit.
Failed to ensure proper hand hygiene techniques by staff, including washing hands for the recommended 20 seconds and proper faucet handling.
Failed to ensure COVID-19 testing compliance for an agency transport staff and lacked a system to track COVID-19 test results for staff.
Report Facts
Census: 148
Sample size: 8
Temperature readings: 86
Temperature readings: 97.6
Temperature readings: 96.8
Temperature readings: 90.2
Temperature readings: 93.7
Temperature readings: 90.8
Temperature readings: 91.3
Temperature readings: 90.2
Temperature readings: 89.7
Temperature readings: 92.9
Temperature readings: 93.1
Temperature readings: 94.5
Staff testing dates: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Screener | Failed to properly screen visitors for COVID-19 symptoms and temperature. | |
| Certified Nursing Aide (CNA) | Interviewed regarding PPE disposal and hand hygiene practices. | |
| Housekeeper | Interviewed regarding PPE disposal and housekeeping equipment on COVID-19 unit. | |
| Licensed Practical Nurse (LPN) | Observed improper hand hygiene during meal tray distribution. | |
| Registered Dietitian (RD) | Observed improper PPE doffing and hand hygiene practices. | |
| Licensed Nursing Home Administrator (LNHA) | Interviewed regarding COVID-19 testing policies and practices. | |
| Director of Nursing (DON) | Interviewed regarding COVID-19 testing policies and practices. | |
| Assistant Director of Nursing/Infection Preventionist (ADON/IP) | Interviewed regarding infection control practices and COVID-19 testing. | |
| Employee Health/Registered Nurse (EH/RN) | Responsible for conducting COVID-19 tests for staff and maintaining testing logs. | |
| Certified Home Health Aide/Transport (CHHA/T) | Agency staff member who was not properly tested or tracked for COVID-19 testing. |
Inspection Report
Abbreviated Survey
Census: 154
Deficiencies: 3
Date: Nov 19, 2020
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 infection control.
Findings
The facility failed to ensure proper use of personal protective equipment (PPE) by housekeeping staff, lacked designated housekeeping equipment for COVID-19 positive units, and had incomplete and inaccurate employee COVID-19 entry screening logs. These deficiencies were observed during interviews, observations, and record reviews.
Deficiencies (3)
Housekeeper did not wear the required gown when entering a resident's room on Contact Precautions.
Housekeeping equipment and supplies were not designated for the COVID-19 positive unit, risking cross-contamination.
Employee COVID-19 entry screening logs were incomplete and inaccurate, missing temperatures and last names, and included implausible temperature readings without rechecks.
Report Facts
Census: 154
Sample size: 4
Missing temperature entries: 5
Low temperature readings: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Observed not wearing gown in Contact Precautions room; medically excused from N-95 respirator mask; involved in PPE use deficiency | |
| Director of Housekeeping | Acknowledged oversight in designating housekeeping equipment for COVID-19 unit and PPE use issues | |
| Licensed Nursing Home Administrator | LNHA | Acknowledged deficiencies in screening logs and PPE compliance |
| Regional Director/Registered Nurse | RN | Confirmed PPE requirements and deficiencies |
| Screener | Responsible for employee COVID-19 screening and temperature logging; logs found incomplete and inaccurate |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 14, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, abuse reporting, care planning, medication storage, infection control, and sanitation.
Findings
The facility was found deficient in multiple areas including failure to provide residents with accessible room lighting, failure to report and investigate a resident-to-resident physical altercation, incomplete care plans for residents requiring oxygen and urinary catheter care, improper documentation of medication refrigerator temperatures, inadequate hand hygiene practices, improper use of multi-use linen carts, and unsanitary conditions in the dumpster area.
Deficiencies (6)
Facility failed to provide residents with a means to readily access room lights while in bed for 70 of 70 rooms toured.
Facility failed to timely report a resident to resident physical altercation to the New Jersey Department of Health and failed to thoroughly investigate the incident for Resident #4.
Facility failed to develop a comprehensive, person-centered Care Plan for Resident #107 requiring oxygen and Resident #108 with a urinary Foley catheter.
Facility failed to maintain accurate documentation to ensure proper storage of refrigerated medications on 2 of 3 nursing units (N3 and N4).
Facility failed to follow appropriate infection control protocols for handwashing on 3 of 3 units observed (Units NA2, N3, N4), ensure multi-use soiled linen and garbage carts were properly utilized to prevent the spread of infection for 1 of 3 units (Unit N3), and failed to maintain a clean and sanitary environment for storage of refrigerated medications in 1 of 3 nursing units (Unit N4).
Facility failed to maintain the dumpster area in a sanitary manner in order to avoid pests.
Report Facts
Rooms without overbed lights: 70
Residents reviewed for care plans: 33
Missing refrigerator temperature recordings: 14
Residents in dining room observed: 24
Trash bags observed outside dumpster: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #458 | Resident | Demonstrated difficulty accessing room lights. |
| Resident #4 | Resident | Involved in physical altercation not reported properly. |
| Administrator | Interviewed regarding incomplete investigation and reporting of resident altercation. | |
| Director of Nursing | DON | Interviewed regarding abuse reporting and care plan responsibilities. |
| Licensed Practical Nurse | LPN | Documented incident report for resident altercation. |
| Registered Nurse Clinical Coordinator | RN/CC | Interviewed about incident report and investigation process. |
| Risk Management Nurse | RN | Interviewed about incident report review and abuse classification. |
| Social Worker | SW | Interviewed about resident altercation follow-up and documentation. |
| Licensed Practical Nurse/Unit Manager | LPN/UM | Interviewed regarding care plan updates and medication refrigerator temperature logs. |
| Certified Nursing Assistant | CNA | Observed and interviewed regarding hand hygiene and linen cart use. |
| Wellness Support Staff | WS | Observed and interviewed regarding hand hygiene practices. |
| Housekeeping Supervisor | HS | Interviewed about cleaning schedules for medication rooms. |
| Food Service Director | FSD | Interviewed about dumpster area sanitation. |
Viewing
Loading inspection reports...
