Inspection Reports for Sinai Post-Acute, Nursing & Rehab Center
65 Jay St, Newark, NJ 07103, USA, NJ, 07103
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Notice
Deficiencies: 0
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 explains 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: 387
Deficiencies: 3
Aug 1, 2024
Visit Reason
The inspection was conducted based on complaints NJ00175921, NJ00160483, and NJ00159461 to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found not in compliance due to failure to timely review and revise care plans for residents, failure to follow physician orders and medication administration policies for two residents, and failure to maintain required minimum staff-to-resident ratios on multiple shifts.
Complaint Details
Complaint numbers NJ00175921, NJ00160483, and NJ00159461 triggered the survey. The facility was found not in compliance based on these complaints.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to review and revise the care plan timely for 1 of 5 sampled residents. | SS=D |
| Failure to follow physician's orders and medication administration policy for 2 residents. | SS=D |
| Failure to maintain required minimum staff-to-resident ratios as mandated by the state of New Jersey for 12 of 14 day shifts and 2 of 14 evening shifts. | — |
Report Facts
Census: 387
Sample Size: 5
Staffing Deficiencies: 12
Staffing Deficiencies: 2
Required CNAs: 43
Inspection Report
Complaint Investigation
Census: 406
Deficiencies: 9
Jul 11, 2024
Visit Reason
A complaint survey was conducted at Sinai Post Acute Nursing and Rehab Center from 07/11/24 through 07/15/24 to determine compliance with 42 CFR Part 483 for Long Term Care facilities.
Findings
The facility was found not in substantial compliance with federal requirements, with Immediate Jeopardy identified due to failure to provide 11 residents autonomy to participate in group activities, community dining, dignified meal service, communication with visitors, freedom to leave rooms at will, and freedom from physical restraints. Admission agreements were also not signed by these residents. The facility implemented corrective actions including discharging all affected residents and ceasing admissions of similar residents. The Immediate Jeopardy was removed as of 07/26/24.
Complaint Details
Complaint # NJ 175415. Immediate Jeopardy identified due to failure to provide autonomy and rights to 11 residents. Immediate Jeopardy removal plan accepted and verified on 07/29/24.
Severity Breakdown
SS=K: 8
SS=E: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to provide residents autonomy to participate in group activities, community dining, dignified meal service, communication with visitors, freedom to leave rooms at will, and freedom from physical restraints. | SS=K |
| Failure to ensure residents signed Admission Agreements on admission. | SS=K |
| Failure to treat residents with respect and dignity, including freedom from physical restraints and seclusion. | SS=K |
| Failure to promote and facilitate resident self-determination including choice of activities, schedules, and interaction with community. | SS=K |
| Failure to ensure residents are free from verbal, mental, sexual, physical abuse, corporal punishment, or involuntary seclusion. | SS=K |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey. | SS=E |
| Failure to provide meaningful group and individualized activity programs reflecting resident preferences. | SS=E |
| Failure to establish and maintain effective systems to safely meet residents' needs, including policies on resident rights, physical restraints, and self-determination. | SS=K |
| Failure to ensure residents were free from physical or chemical restraints imposed for discipline or convenience and not required to treat medical symptoms. | SS=K |
Report Facts
Census: 406
Deficiency counts: 10
Staffing ratios: 14
CNA staffing: 24
CNA staffing: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Nurse for Residents #8 and #9, described restrictions and care practices |
| LPN/UM #1 | Licensed Practical Nurse/Unit Manager | Described care and restrictions for Residents #3 and #7 |
| Unit Manager #3 | Unit Manager | Described restrictions on Justice Involved Residents and shower schedule |
| MDS Coordinator | Minimum Data Set Coordinator | Described MDS completion status for Justice Involved Residents |
| Social Service Designee | Social Service | Described admission process and resident rights education |
| Administrator | Facility Administrator | Described facility awareness of restrictions and regulatory challenges |
Inspection Report
Complaint Investigation
Census: 346
Deficiencies: 12
Dec 22, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including investigation of multiple complaints.
Findings
The facility was found to be in substantial compliance with emergency preparedness requirements but had deficiencies related to maintaining a safe, clean, and homelike environment, accuracy of assessments, comprehensive care plans, infection control, food safety, life safety code violations including egress doors, fire alarm system, sprinkler system, and electrical systems. Deficiencies were identified through observation, interviews, and record reviews.
Complaint Details
Complaint numbers NJ00159458, NJ00159211, NJ00159056, NJ00158923, NJ00158871, NJ00155764, NJ00151577, NJ00150854 were investigated during this survey.
Deficiencies (12)
| Description |
|---|
| Facility failed to maintain resident's equipment and living areas in a clean and home-like manner, evidenced by a hole in the wall next to resident #171's bed. |
| Facility failed to accurately code the Minimum Data Set (MDS) for residents #346 and #548. |
| Facility failed to develop comprehensive, person-centered care plans for residents #171, #313, and #2. |
| Facility failed to revise a resident's comprehensive care plan for resident #103. |
| Facility failed to ensure medication times were adjusted to accommodate dialysis for resident #11. |
| Facility failed to ensure physician visits were documented timely for multiple residents including #176, #141, #154, #174, #255, #103, #22, and #104. |
| Facility failed to ensure food service equipment was stored properly and food safety practices were followed. |
| Facility failed to provide required emergency egress doors with proper signage, thumb turn locks, and maintenance. |
| Facility failed to maintain fire alarm system and sprinkler system in accordance with NFPA standards. |
| Facility failed to maintain electrical systems including emergency generator and electrical outlets with GFCI protection. |
| Facility failed to maintain infection prevention and control program including hand hygiene compliance. |
| Facility failed to maintain linen chute doors and corridor doors with proper fire resistance and self-closing mechanisms. |
Report Facts
Resident census: 346
Sample size: 38
Deficiency counts: 12
Staffing ratios: 42
Fire extinguisher counts: 48
Exit doors inspected: 36
Resident sleeping rooms: 222
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Interviewed regarding hole in the wall next to resident #171's bed. |
| Licensed Practical Nurse #1 | LPN | Interviewed about hole in the wall in resident #171's room. |
| Licensed Practical Nurse Unit Manager #1 | LPN/UM | Interviewed about hole in the wall and resident care plans. |
| Maintenance Director | MD | Interviewed regarding hole in the wall and fire safety deficiencies. |
| Director of Nursing | DON | Interviewed regarding hole in the wall, MDS coding, care plans, and other deficiencies. |
| Licensed Nursing Home Administrator | LNHA | Interviewed regarding care plan concerns and other deficiencies. |
| Registered Dietitian | RD | Interviewed regarding nutritional care plans and dietary deficiencies. |
| Physician | Physician | Responsible for resident care and documentation; deficiencies noted in physician visits. |
| Food Service Director | FSD | Interviewed regarding food safety and kitchen equipment. |
| Regional Plant Operations Director | RPOD | Involved in facility layout and fire safety inspections. |
Inspection Report
Routine
Census: 335
Deficiencies: 0
Dec 4, 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
Complaint Investigation
Census: 349
Deficiencies: 1
Sep 7, 2022
Visit Reason
The inspection was conducted based on a complaint survey (Complaint #: NJ00157788) to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility failed to report an incident involving a resident who left the facility without staff authorization to the New Jersey Department of Health as required by state law and facility policies. The resident was denied admission but was dropped off and left the facility without being reported as an elopement.
Complaint Details
Complaint #: NJ00157788. The complaint investigation found the facility did not report a resident who left the facility without authorization, violating reporting requirements. The incident was substantiated by interviews and record reviews.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an unauthorized resident elopement to the New Jersey Department of Health as required by facility policy and state law. | SS=D |
Report Facts
Census: 349
Sample Size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Admission Director | Interviewed regarding the resident referral and admission process related to the deficiency. | |
| Director of Nursing | Interviewed and involved in the denial of admission and failure to report the resident elopement. |
Inspection Report
Routine
Census: 327
Deficiencies: 0
Aug 4, 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: 5
Inspection Report
Routine
Census: 322
Deficiencies: 0
Jan 10, 2022
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
Deficiencies: 1
Aug 18, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Findings
The facility was found not in compliance with New Jersey staffing requirements for certified nurse aides during the 7:00 AM to 3:00 PM shift on multiple days from August 1 to August 7, 2021. The Administrator and Director of Nursing acknowledged the staffing concerns and reported efforts to hire new CNAs and offer incentives.
Complaint Details
The complaint was substantiated as the facility failed to meet the minimum staffing requirements for certified nurse aides during the specified shifts and dates. The facility acknowledged the issue and is taking corrective actions.
Deficiencies (1)
| Description |
|---|
| Failure to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey during the 7:00 AM - 3:00 PM shift on 8/1/21 through 8/7/21. |
Report Facts
Dates of deficient staffing: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Discussed staffing ratio concerns with surveyor and acknowledged efforts to hire new CNAs and offer incentives. | |
| Director of Nursing | Discussed staffing ratio concerns with surveyor and acknowledged efforts to hire new CNAs and offer incentives. |
Inspection Report
Complaint Investigation
Census: 346
Deficiencies: 0
Jul 6, 2021
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaint numbers NJ143392, NJ142973, NJ142242, and NJ141037.
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.
Complaint Details
Complaint numbers NJ143392, NJ142973, NJ142242, and NJ141037 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 17
Inspection Report
Complaint Investigation
Census: 338
Deficiencies: 0
Jun 9, 2021
Visit Reason
The inspection was conducted as a complaint survey to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in compliance with the regulatory requirements based on the complaint survey.
Complaint Details
The survey was complaint-based and the facility was found compliant; no deficiencies were cited.
Report Facts
Sample Size: 4
Inspection Report
Complaint Investigation
Census: 333
Deficiencies: 2
Apr 21, 2021
Visit Reason
The inspection was conducted based on complaints NJ 144443 and 144778 to investigate compliance with food safety requirements related to food procurement, storage, preparation, and serving sanitary practices.
Findings
The facility failed to ensure that the refrigerator in the 3rd floor dayroom was checked and documented daily for temperature, and that residents' food items stored there were properly labeled and dated. This posed a risk to food safety and resident health.
Complaint Details
Complaint #: NJ 144443, 144778. The facility was found not in substantial compliance with 42 CFR PART483, SUBPART B, based on this complaint visit.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure daily temperature checks and documentation of the 3rd floor dayroom refrigerator. | SS=D |
| Failure to label and date residents' food items stored in the refrigerator. | SS=D |
Report Facts
Census: 333
Days without temperature documentation: 9
Sample size: 4
Audit frequency: 2
Audit duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Responsible for checking and documenting refrigerator temperature and ensuring food labeling | |
| Administrator | Confirmed responsibilities of Unit Manager and nursing staff regarding refrigerator temperature checks and food labeling |
Inspection Report
Complaint Investigation
Census: 323
Deficiencies: 0
Dec 22, 2020
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ00138101 and NJ00131623.
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.
Complaint Details
Complaint numbers NJ00138101 and NJ00131623 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample size: 7
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